MAJOR EXTENDED HEPATIC RESECTIONS IN DISEASED LIVER USING HYPOTHERMICPROTECTION - PRELIMINARY-RESULTS FROM THE FIRST 12 PATIENTS TREATED WITH THIS NEW TECHNIQUE

BACKGROUND: Hepatic vascular exclusion allows the performance of major hepatic resections with minimal intraoperative blood loss, We have pr eviously shown that normothermic ischemia can be tolerated by a health y liver for up to 90 minutes, and this period is increased to 4 hours if the liver is cooled to 4 degrees C using University of Wisconsin so lution. STUDY DESIGN This study assessed whether these techniques coul d be successfully applied for patients requiring resection of a diseas ed liver, which is more sensitive to ischemic damage, Between July 199 0 and May 1994, 12 patients (6 men, 6 women; mean age, 57.8 years) in whom the planned hepatic resection was believed to require hepatic vas cular exclusion for more than 1 hour were treated with perfusion with the University of Wisconsin solution, The surgical procedures were rig ht hepatectomy (one patient), extended right hepatectomy (seven patien ts), and extended left hepatectomy (four patients), The underlying hep atic disease was cirrhosis or severe fibrosis with hepatocellular carc inoma (four patients), cholestasis (due to cholangiocarcinoma and bili ary stricture, one patient each), and more than 30 percent steatosis a fter treatment of hepatic metastases with chemotherapy (six patients), The University of Wisconsin solution that had been cooled to 4 degree s C was perfused through a cannula placed in the portal vein or the he patic arterial branch of the segment to be resected, but with flow dir ected toward the liver that should be retained and effluent fluid drai ned through a cavotomy, Before reperfusion, the liver was rinsed with Ringer's lactate solution, which was also 4 degrees C. RESULTS: The me an duration of hepatic ischemia was 121 minutes (range, 65 to 250 minu tes), and venovenous bypass was used in three cases, The mean amount o f blood transfused intraoperatively was 4.3+/-4 U; four cases required no transfusion, One patient died on postoperative day seven of portal vein thrombosis, The median hospital stay was 21 days (range, 12 to 5 6 days), Postoperative complications consisted of pneumonia (one patie nt), liver insufficiency (one patient, who recovered spontaneously), a nd subphrenic abscess (one patient), The postoperative tests of hepati c function were altered to the same degree as that seen after hepatic vascular exclusion of less than 1-hour duration in healthy livers, All patients who left the hospital were alive at 1 year. CONCLUSIONS: Coo ling of the hepatic parenchyma allowed us to perform major hepatic res ection in patients with diseased livers using hepatic vascular exclusi on for longer than 1 hour without increased morbidity or mortality, Ho wever, because of particular difficulties due to the size or location of the lesions, the application of these new techniques should only be considered for the largest and most complex hepatic resections for wh ich hepatic vascular exclusions longer than 1 hour are foreseen.