Utilisation sélective des clampages vasculaires au cours des hépatectomies majeures

Selective use of vascular occlusions in major hepatectomies.

Objective: To report the results of a selective use of vascular occlusions in major hepatectomies according to the size and location of the hepatic lesion.

Background: Total vascular exclusion (TVE) and portal triad clamping (PTC) ensure efficient hemostatic effect but lead to warm ischemia of the liver. Lobar vascular occlusion (LVO) avoids warm ischemia of the remnant liver but could result in increased blood loss.

Patients and methods: Sixty consecutive major hepatectomies were studied. TVE was applied in 22 patients with large lesions (=10 cm) or lesions with connections to the major hepatic veins or inferior vena cava. PTC (n=15) and LVO (n=23) were applied in remaining cases.

Results: Clamping method was efficient in 87%, 93% and 100% for LVO, PTC and TVE, respectively. Median blood transfusions were 0,3 and 2 units for LVO, PTC and TVE, respectively. Postoperative aminotransferase peak value was significantly lower after LVO than after PTC or TVE, while those peaks were not statistically different with these latter two methods. Postoperative prothrombin time fall value was identical in the three groups. Mortality was 3.3% (2/60) and was not influenced by the type of clamping, but both deaths and most complications occurred in patients with abnormal underlying liver parenchyma.

Conclusion: Provided that adequate techniques are used, the need for blood transfusions is more dependent on the characteristics of the resected tumor than on the type of clamping used. Total vascular exclusion does not create more ischemic injury to the liver than portal triad clamping and it should be recommended for the resection of large or strategically located tumors. Other tumors can be resected in more than 80% of the cases with LVO, thus avoiding ischemia to the remnant liver. With the control of hemorrhage, pathology of underlying liver parenchyma has emerged as the main prognostic factor in major liver resections.