What are the key factors and strategies to minimize and manage bleeding in patients undergoing hepatectomy?

Key Factors and Strategies to Minimize and Manage Bleeding During Hepatectomy

The most effective approach to minimize bleeding during hepatectomy includes maintaining low central venous pressure, using appropriate surgical techniques, and addressing patient-specific risk factors such as cirrhosis, acute kidney injury, and hypofibrinogenemia. 1, 2

Patient-Related Risk Factors

• Presence of cirrhosis, especially Child-Turcotte-Pugh class C, significantly increases bleeding risk during hepatectomy 2
• Acute kidney injury increases bleeding risk, particularly in patients with acute-on-chronic liver failure 1, 2
• Hypofibrinogenemia has been identified as an independent predictor of bleeding in patients with acute-on-chronic liver failure 1, 2
• Bacterial infections can significantly worsen bleeding risk during hepatectomy 2
• Preoperative anemia is independently associated with increased risk of major morbidity following hepatectomy 3
• Clinically significant portal hypertension is a significant predictor of intraoperative blood loss 4

Preoperative Assessment and Management

• Traditional coagulation tests (INR, PT) often overestimate bleeding risk in hepatectomy patients and do not reliably predict procedural bleeding 2
• Laboratory evaluation of hemostasis with the aim of predicting post-procedural bleeding is not indicated for low-risk procedures (Level of Evidence 4, strong recommendation) 1
• For high-risk procedures, laboratory tests may serve to provide baseline status but are generally not predictive of bleeding risk 1
• Prophylactic blood product transfusion based solely on laboratory values is discouraged as it may increase complications without reducing bleeding 2
• Addressing acute and/or chronic kidney dysfunction before elective procedures can reduce bleeding risk 2

Intraoperative Strategies

• Low central venous pressure (below 5 cm H2O) with close monitoring is associated with decreased blood loss during liver resection 1, 2
• Stroke volume variation (SVV) monitoring has shown better results than central venous pressure (CVP) monitoring in reducing blood loss during laparoscopic liver surgery 2
• Primary surgical intention should be to control hemorrhage, control bile leak, and institute intensive resuscitation as soon as possible (Grade of Recommendation 2B) 1
• Major hepatic resections should be avoided initially and considered subsequently only in cases of large devitalized liver portions and in centers with necessary expertise (Grade of Recommendation 3B) 1
• Angioembolization is a useful tool in case of persistent arterial bleeding (Grade of Recommendation 2A) 1
• Ultrasound guidance during procedures can reduce complications and bleeding episodes 1

Surgical Techniques for Hemorrhage Control

• Initial maneuvers for major hemorrhage include hepatic manual compression and hepatic packing 1
• For persistent bleeding despite initial maneuvers, consider ligation of vessels in the wound, hepatic debridement, balloon tamponade, shunting procedures, or hepatic vascular isolation 1
• If selective hepatic artery ligation is necessary, cholecystectomy should be performed to avoid gallbladder necrosis 1
• Portal vein injuries should be repaired primarily; portal vein ligation should be avoided due to risk of liver necrosis or massive bowel edema 1
• For retro-hepatic caval or hepatic vein injuries, options include tamponade with hepatic packing, direct repair (with or without vascular isolation), or lobar resection 1

Fluid Management and Transfusion Strategy

• Excessive administration of crystalloids should be avoided as much as blood loss during liver surgery 1
• Balanced crystalloids (e.g., Ringer's lactate) are recommended as maintenance fluid and colloids as volume expander (e.g., human albumin) 1
• Postoperative weight fluctuation should be carefully monitored; weight gain >3.5 kg on postoperative day 2 is an independent risk factor for major complications 1
• Restrictive transfusion strategy (transfusion with hemoglobin <7 g/dl with a target of 7-9 g/dl) is recommended to avoid increasing portal pressure 2
• Perioperative red blood cell transfusions are independently associated with worse short-term outcomes and prolonged length of stay 5

Special Considerations for High-Risk Cases

• Right major hepatectomy for large primary liver cancers, tumor compression of the inferior vena cava, and anterior approach without liver-hanging maneuver are risks for massive bleeding 6
• Preparation of rapid infusion devices is necessary for high-risk cases to avoid prolonged hypotension 6
• Operative time >360 minutes, blood loss >400 mL, and serum albumin levels <3.5 g/dL are independent risk factors for morbidity 7
• Tumor size, serum creatinine, clinically significant portal hypertension, and major hepatectomy are significant predictors of intraoperative blood loss 4

Post-Procedure Management

• Patients with cirrhosis undergoing invasive procedures should be monitored for bleeding complications in the same way as patients without cirrhosis (Level of Evidence 3, strong recommendation) 1
• A multimodal approach to postoperative nausea and vomiting should be used, with at least 2 antiemetic drugs such as dexamethasone and ondansetron 1
• Early mobilization after liver surgery should be established from the operative day until hospital discharge 1

Common Pitfalls to Avoid

• Overreliance on INR/PT values to predict bleeding risk 2
• Unnecessary prophylactic blood product transfusions based solely on laboratory values 2
• Excessive fluid administration, which can be as harmful as blood loss during liver surgery 2
• Neglecting to treat underlying conditions like infections or acute kidney injury that may contribute more to bleeding risk than coagulation abnormalities 2