LIVER RESECTION USING TOTAL VASCULAR EXCLUSION

Background. Total vascular exclusion (TVE) is a technique of liver res ection that includes controlling both the suprahepatic and infrahepati c vena cava in addition to portal inflow at the time of parenchymal tr ansection. We report a series of 61 liver resections in 60 patients us ing this technique. Methods. A retrospective review of 61 procedures i n 60 patients using TVE between 1990 and 1997 was carried out. No pati ent had cirrhosis. Parameters analyzed included age, gender diagnosis, procedure, operative time, clamp time, intraoperative transfusion req uirements, postoperative laboratory studies, length of stay (intensive care unit, ward), mortality, and morbidity. Results. TVE was sustaine d hemodynamically in all patients. The mean age of the 34 men and 27 w omen was 56 years (+/-15 years); 21% were older than 70 years. Eleven percent of the patients had benign lesions; 70% of the malignant tumor s were metastatic. Twenty-five percent of the procedures were major or extended lobectomies. The mean operative and clamp times were 330 +/- 83 and 39 +/- 13.2 minutes, respectively; 68% had clamp times of <45 minutes. The mean intraoperative red blood cell units was 1.45 +/- 1.9 3 with a range of 0 to 8 units; 48% required no transfusion and 80% re ceived 2 units or less. There was 1 perioperative death for a mortalit y rate of 1.6%. The morbidity rate was 36%, which included 4 patients with postoperative liver dysfunction. Complications were not associate d with transfusion but with clamp times exceeding 45 minutes. Liver dy sfunction occurred with clamp times more than 60 minutes, particularly if the remaining liver parenchyma was histologically abnormal or the remnant was small. Conclusions. TVE is hemodynamically safe, even in p atients older than 70 years. Blood loss during parenchymal transection is minimal; mortality and morbidity are low. The optimal clamp time i s less than 45 minutes. Liver dysfunction is associated with clamp tim es exceeding 1 hour, particularly if the remaining parenchyma is abnor mal or small.