Raffaella Reineke

Intraoperative monitoring of stroke volume variation versus central venous pressure in laparoscopic liver surgery: a randomized prospective comparative trial.

BACKGROUND Central venous pressure (CVP) is used as a marker of cardiac preload to control intraoperative blood loss in open hepatectomies, while its reliability in laparoscopy is less certain. The aim of this randomized prospective trial was to evaluate the outcome of laparoscopic resections performed with stroke volume variation (SVV) or CVP monitoring. METHODS All candidates for laparoscopic liver resection were assigned randomly to SVV or to CVP groups. Outcome was evaluated included conversion rate, cause of conversion, intraoperative blood loss, need for transfusions, length of surgery and postoperative results. RESULTS Ninety consecutive patients were enrolled: both SVV and CVP groups included 45 patients each and were comparable in terms of patient and disease characteristics. A reduced rate of conversion was recorded in the SVV compared to the CVP group (6.7% and 17.8% respectively, p = 0.02). Blood loss was lower in the SVV group (150 mL), compared to the CVP group (300 mL, p = 0.04). Morbidity, mortality, length of stay and functional recovery were comparable. On multivariate analysis, lesion location, extent of hepatectomy and type of cardiac preload monitoring were associated significantly to risk of conversion. CONCLUSION SVV monitoring in laparoscopic liver surgery improves intraoperative outcome, thus enhancing the benefits of the minimally-invasive approach and fast-track protocols.

The clinical and biological impacts of the implementation of fast-track perioperative programs in complex liver resections: A propensity score-based analysis between the open and laparoscopic approaches

Background: The aim of this study was to evaluate the impact of the fast‐track approach in patients undergoing complex liver procedures and to analyse factors that influence morbidity and functional recovery. Methods: Hepatic resections (2014–2016) were stratified according to difficulty score, obtaining a group of 215 complex resections (102 laparoscopic, 163 open). The laparoscopic group was matched by propensity score with open patients to obtain the minimally invasive liver surgery group (n = 102) and the open group (n = 102). Results: Groups were similar in terms of patient and disease characteristics. The postoperative morbidity was 31.4% in the minimally invasive liver surgery and 38.2% in the open group (P = .05), and functional recovery was shorter in the minimally invasive liver surgery (respectively 4 versus 6 days, P = .041). The adherence to fast‐track was high in both groups, with several items with higher penetrance in the minimally invasive liver surgery group. Among factors associated with morbidity and functional recovery, a laparoscopic approach and strict adherence to a fast‐track protocol resulted in protective factors. Conclusion: The combination of minimally invasive approaches and fast‐track protocols allows a reduced rate of postoperative morbidity and satisfactory functional recovery even in the setting of complex liver resections. When the laparoscopic approach is not feasible, strict adherence to a fast‐track program is associated with the achievement of adequate results and should be implemented.

Liver resection for hepatocellular carcinoma within a fast-track management: a propensity-score matched analysis between open and laparoscopic approach

Aim: The study was designed to assess the implications of enhanced recovery after surgery (ERAS) approach in patients submitted to open liver resection for hepatocellular carcinoma (HCC) comparing their short term outcome with patients treated by laparoscopic approach, in a case-matched design. Methods: The open-group (n = 60) was matched in a ratio of 1:1 with patients undergoing laparoscopic liver resection for HCC (Lap-group, n = 60), with a matching achieved on a basis of propensity scores including 6 covariates representing patients characteristics and severity of the disease. Primary outcome analysis was performed in terms of ERAS-specific items and postoperative morbidity and mortality. Results: Overall morbidity and mortality were comparable between groups. Incidence of ascites was slightly higher in the opencompared with the Lap-group (respectively 11.7% and 13.3%), without statistical significance. The need for introduction or increase of chronic diuretic therapy was significantly higher in the open-compared with the Lap-group (16.7% vs. 11.7%, P = 0.046). Furthermore, ascites more frequently required percutaneous drainage in the open-compared with the Lap-group (5% vs. 1.7% respectively, P = 0.041). Conclusion: In patients who can’t benefit from minimally-invasive approach because of disease characteristics, ERAS management seems to be associated with an improved postoperative functional recovery and postoperative outcomes, comparable to those of the minimally invasive approach. ABSTRACT

Anesthesia and Intraoperative Management in Liver Surgery

Hepatic surgery, even for benign tumors, may be considered a great challenge for the anesthetist. The role of the anesthetist in this surgery is really important, and success is a consequence of a careful evaluation of both the patient and the kind of resection that must be done together with the surgeon.