ORIGINAL SCIENTIFIC ARTICLES
Perioperative Management of Hepatic Resection
Toward Zero Mortality and Morbidity: Analysis of
793 Consecutive Cases in a Single Institution
Toshiya Kamiyama, MD, Kazuaki Nakanishi, MD, Hideki Yokoo, MD, Hirofumi Kamachi, MD,
Munenori Tahara, MD, Kenichiro Yamashita, MD, Masahiko Taniguchi, MD, Tsuyoshi Shimamura, MD,
Michiaki Matsushita, MD, Satoru Todo, MD, FACS
The mortality rates associated with hepatectomy are still not zero. Our aim was to define the risk
factors for complications and to evaluate our perioperative management.
STUDY DESIGN: Between 2001 and 2008, 793 consecutive patients (547 men and 246 women; mean age ⫾ SD,
56.1 ⫾ 14.9 years) underwent hepatectomy without gastrointestinal resection and choledocojejunostomy at our center. Of these patients, 354 (44.6%) were positive for the hepatitis B virus
surface antigen and/or the hepatitis C virus antibody. We categorized 783 (98.7%) patients as
Child-Pugh class A. Major resection (sectionectomy, hemihepatectomy, and extended hemihepatectomy), was performed in 535 patients (67.5%) and re-resection in 81 patients (10.2%).
RESULTS:
The median operative time was 345.5 minutes and median blood loss was 360 mL. The rate of
red blood cell transfusion was 6.8%. The morbidity rate was 15.6%. Reoperations were performed in 19 patients (2.4%). The mean postoperative hospital stay was 18.4 ⫾ 10.4 days. The
in-hospital mortality rate was 0.1% (1 of 793 patients; caused by hepatic failure). The independent relative risk for morbidity was influenced by an operative time of more than 360
minutes, blood loss of more than 400 mL, and serum albumin levels of less than 3.5 g/dL, as
determined using multivariate logistic regression analysis.
CONCLUSIONS: Shorter operative times and reduced blood loss were obtained by improving the surgical technique and using new surgical devices and intraoperative management, including anesthesia.
Additionally, decision making using our algorithm and perioperative management according to
CDC guidelines reduced the morbidity and mortality associated with hepatectomy. (J Am Coll
Surg 2010;211:443–449. © 2010 by the American College of Surgeons)
BACKGROUND:
Liver resection is indicated for hepatocellular carcinoma
(HCC), metastatic liver tumor, biliary malignancy, living
donor liver transplantation, and other liver tumors. Liver
resection for HCC has the highest local controllability of
all local treatments and promotes a good survival rate.1,2
Because approximately 90% of patients with HCC have
been infected with the hepatitis B and/or hepatitis C viruses,
and therefore have chronic hepatitis or cirrhosis,3 the functional reserve of the liver decreases in almost all patients with
HCC. Cirrhotic patients have elevated portal venous pressures, decreased reticuloendothelial system function, and
impaired regeneration and coagulopathy.4 Therefore,
liver resection in cirrhotic patients is associated with
high mortality rates (8.9% to 19.6%).5 Conversely, recent advances in surgical techniques and pre- and postoperative care, including the decision criteria for hepatectomy6,7 and indications for liver resection, have been
applied to extended hepatectomy for hilar bile duct carcinoma,8 living donor liver transplantation,9 and colorectal metastasis.10 The morbidity and mortality rates of
these operations are decreasing, but are still not zero.11,12
In cirrhotic patients with decreased reticuloendothelial
system function, infections associated with the operation
occur easily and increase the probability of liver failure;13
therefore, infection control is very important for hepatectomy. The guidelines for the prevention of surgical site
infection from the CDC14 are useful for prevention of infections associated with operations. We have given pre- and
Disclosure information: Nothing to disclose.
Received March 3, 2010; Revised June 3, 2010; Accepted June 3, 2010.
From the Departments of General Surgery (Kamiyama, Yokoo, Kamachi,
Tahara, Yamashita, Shimamura, Todo) and Organ Transplantation and Regenerative Medicine (Nakanishi, Taniguchi), Hokkaido University Graduate
School of Medicine; and the Department of Health Sciences, School of Medicine, Hokkaido University (Matsushita), Sapporo, Japan.
Correspondence address: Toshiya Kamiyama, MD, Department of General
Surgery, Hokkaido University Graduate School of Medicine, North 15, West
7, Kita-ku, Sapporo 060-8638 Japan. email: t-kamiya@med.hokudai.ac.jp
© 2010 by the American College of Surgeons
Published by Elsevier Inc.
443
ISSN 1072-7515/10/$36.00
doi:10.1016/j.jamcollsurg.2010.06.005
444
Kamiyama et al
Perioperative Management of Hepatectomy
Abbreviations and Acronyms
CUSA
⫽ Cavitron ultrasonic surgical aspirator
HCC
⫽ hepatocellular carcinoma
99m
Tc-GSA ⫽ technetium 99m
diethylenetriaminepentaacetic acid galactosyl
human serum albumin
HH 15
⫽ uptake ratio of heart at 15 minutes to that at
3 minutes
ICGR15
⫽ indocyanine green retention rate at 15
minutes
LHL15
⫽ uptake ratio of liver to liver plus heart at 15
minutes
PTPE
⫽ percutaneous transhepatic portal
embolization
postoperative care according to the guidelines of the CDC
for the past 8 years.
To further improve the outcomes of liver resection, it is
important to identify and prevent the causes of complications. In this study, we reviewed the postoperative courses
of patients undergoing liver resection in our hospital, and
we sought to define the risk factors for complications and
to evaluate our perioperative management.
METHODS
Patients
Between 2001 and 2008, 793 consecutive patients (547
men and 246 women; mean age [⫾SD], 56.1 ⫾ 14.9 years)
underwent hepatectomy without gastrointestinal resection
and choledocojejunostomy at our center. Indications for
resection are shown in Table 1. Three hundred fifty-four
(44.6%) patients were positive for the hepatitis B virus
surface antigen and/or hepatitis C virus antibody. Among
the 793 patients, 783 (98.7%) were categorized as ChildPugh class A. Major resection, which included sectionectomy, hemihepatectomy and extended hemihepatectomy,
was performed in 535 (67.5%) patients (Table 2) and reresection was done in 81 (10.2%) patients. Left hemihepatectomy, left lateral sectionectomy, and limited resection
were laparoscopically performed in 5 patients, 11 patients,
and 5 patients, respectively.
Evaluated factors
The indocyanine green retention rate at 15 minutes
(ICGR15) was measured to evaluate the liver functional
reserve, regardless of the presence or absence of cirrhosis.
Moreover, hepatic receptor imaging with technetium 99m
diethylenetriaminepentaacetic acid galactosyl human serum albumin (99mTc-GSA) facilitates the numerical evaluation of the hepatic functional reserve by means of the
receptor index (uptake ratio of the liver to the liver plus
J Am Coll Surg
Table 1. Indications for Hepatectomy and the Surgical Procedures
Indication/diagnosis
Primary liver tumor
Hepatocellular carcinoma
Cholangiocellular carcinoma
Mixed type
Cystic disease
Other malignant tumor
Metastatic liver tumor
Donor for LDLT
Benign tumor
Hemangioma
Other benign tumor
Echinococcosis
Surgical procedure
Limited resection
Segmentectomy
Sectionactomy
Hemihepatectomy or more
Patients, n
%
412
32
16
8
8
83
145
52.0
4.0
2.0
1.0
1.0
10.5
18.3
9
12
68
1.1
1.5
8.6
194
64
175
360
24.5
8.1
22.1
45.4
LDLT, living donor liver transplantation.
heart at 15 minutes [LHL15]) and the index of blood clearance (uptake ratio of the heart at 15 minutes to that at 3
minutes [HH15]). LHL15 and HH15 are simplified and
universal methods used in 99mTc-GSA scintigraphy analysis. The correlation of LHL15 and HH15 to ICGR15 using a linear regression model is an easy and convenient
method for predicting hepatic functional reserve when using 99mTc-GSA scintigraphy. The converted ICGR15, as
calculated from LHL15 and HH15, categorized by liver
damage severity, also complements the weak points of the
actual measured ICGR15 and is, therefore, useful to evaluate
the hepatic functional reserve.15 The converted ICGR15 and
ICGR15 were used to determine the operative procedure.
An algorithm (Hokkaido University Algorithm), incorporating the ICGR15 and remnant liver volume, was used
to determine the operative procedure (Fig. 1). Anatomic
resection was defined as a resection in which the lesion(s)
are completely anatomically removed on the basis of
Couinaud’s classification, including segmentectomy, sectionectomy, hemihepatectomy, and extended hemihepatectomy, in patients with tolerable functional reserves. Nonanatomic partial resection was defined as a limited
resection. Not all patients who undergo hepatic resection
have uncontrollable ascites. If the ICGR15 is less than 15%
and the resected liver volume is less than 60%, hemihepatectomy or extended hemihepatectomy can be tolerated.
However, if the ICGR15 is less than 15% and the resected
liver volume is greater than 60%, then percutaneous transhepatic portal embolization (PTPE) is performed before
surgery to induce compensatory hypertrophy of the liver
Vol. 211, No. 4, October 2010
Kamiyama et al
Table 2. Clinical Characteristics of the Patients
Clinical characteristic
Gender, male : female
Age (y), ⬍65 : ⱖ65
Operation time (min), ⱕ360 : ⬎360
Blood loss (mL), ⱕ400 : ⬎400
Albumin (g/dL), ⬍3.5 : ⱖ3.5
Total bilirubin (mg/dL), ⬍0.7: ⱖ0.7
ICGR15 (%), ⬍15 : ⱖ15
HBV(⫺)HCV(⫺) : HBV(⫹)HCV(⫺), HBV(⫹)
HCV(⫹), HBV(⫺)HCV(⫹)
Minor resection : major resection
Child-Pugh class A : B
Re-resection, no : yes
n
547 : 246
543 : 250
434 : 359
420 : 373
40 : 753
458 : 335
573 : 220
439 : 354
258 : 535
783 : 10
712 : 81
HBV, hepatitis B virus surface antigen; HCV, hepatitis C virus antibody;
ICGR 15, indocyanine green retention rate at 15 minutes.
remnant after hepatectomy. Between 2001 and 2008,
PTPE was performed on 28 patients. For patients with
an ICGR15 of 15% to 20%, sectionectomy can be performed; for patients with an ICGR15 of 20% to 25%,
segmentectomy can be performed; and for patients with
an ICGR15 of 25% to 40%, a limited resection can be
performed. If the ICGR15 is more than 40%, hepatectomy is contraindicated.
Three-dimensional CT and volumetry
To understand the correlation between vessels and the tumor, and for preoperative simulations, we reconstructed
3-dimensional images using multidetector row-CT (MD-CT;
Toshiba Aquilion Multi-Slice CT; Toshiba Medical Systems
Co Ltd). All datasets acquired using helical scanning were
reconstructed to isotropic voxel datasets. Reconstructed data
were transferred to a 3-dimensional workstation (Virtual Place
Advance; Medical Imaging Laboratory).16 The volumes of
the liver parenchyma and tumors were also measured using
Perioperative Management of Hepatectomy
445
Virtual Place Advance and the effective resection of ratio (%)
([volume of liver to be resected ⫺ tumor volume/total liver
volume ⫺ tumor volume] ⫻ 100)17 was calculated.
Preoperative care
Preparation of the patient was performed according to the
1999 CDC guidelines for prevention of surgical site infections. We administered 2 g cefazolin for antimicrobial prophylaxis no more than 30 minutes before the skin was
incised. When the duration of an operation was expected to
exceed the time in which therapeutic levels of cefazolin
could be maintained, cefazolin was administered every 4
hours after the previous administration. After the operation, 2 g cefazolin was given twice daily for 3 days according to a previous report,18 although the CDC guidelines
recommended maintaining therapeutic levels of the antimicrobial agent in both serum and tissues throughout the
operation and until, at most, a few hours after the incision
is closed in the operating room.14
Hepatectomy
Transection of the liver parenchyma was performed using
the hook spatula of an ultrasonic harmonic scalpel (Ethicon EndoSurgery) and a Salient DS3.0 Monopolar Sealer
(DS3.0) (Salient Surgical Technologies) or bipolar cautery
with a saline irrigation system. Vessels were carefully exposed with the hook spatula. Vessels less than 2 mm in
diameter were coagulated with the DS3.0 or bipolar cautery and cut with the hook spatula. Vessels greater than 2
mm in diameter were ligated. Inflow occlusion was applied
in an intermittent manner, with 15 minutes of occlusion
alternated with 5 minutes of reperfusion. During transection of the liver parenchyma, the central venous pressure
was maintained below 5 cm H2O to prevent venous hemorrhage. Intraoperative cholangiography was routinely performed to map the bile duct before resection of the paren-
Figure 1. Hokkaido University Algorithm for hepatic resection. This algorithm used the ICGR15 and remnant
liver volume to determine the operative procedure. ICGR15, indocyanine green retention rate at 15 minutes;
ERR, effective resection of ratio (%) ([volume of liver to be resected ⫺ tumor volume/total liver volume ⫺
tumor volume] ⫻ 100); Hemi or Extended, hemihepatectomy or extended hemihepatectomy; PTPE, percutaneous transhepatic portal embolization.
446
Kamiyama et al
Perioperative Management of Hepatectomy
J Am Coll Surg
Figure 2. Median operative time. The median operative time from
2001 to 2008 was 345.5 minutes.
Figure 3. Median blood loss. The median blood loss from 2001 to
2008 was 360 mL.
chyma, to confirm the branch of the bile duct to be
preserved, and to ensure there was no leakage of bile. Since
2005, if leakage of the contrast medium or an air bubble
was observed, a C-tube, which was easily removable, was
inserted in the cystic duct to decompress the bile duct. A
closed suction drain (Davol ReliaVac) was used as an abdominal drainage tube. This drain was routinely removed 3
days after hepatectomy. However, when the discharge fluid
was bloody and/or the bilirubin level of the discharge fluid
was more than 5 mg/dL, the drainage tube was left in until
the discharge fluid became serous.
plications from our series. In total, 53 patients suffered
from bile leakage and/or an abscess, and a reoperation was
performed on 15 patients, change of drainage tube or echoguided puncture in 25 patients, and conservative therapy
in 13 patients. Reoperations caused by postoperative bleeding and bile leakage occurred in 19 patients (2.4%). The
mean postoperative hospital stay was 18.4 ⫾ 10.4 days
and the in-hospital mortality rate was 0.1% (1 of 793
patients; caused by hepatic failure).
Results from multivariate logistic regression analysis
evaluating the independent relative risk for morbidity are
shown in Table 4. The independent relative risk for morbidity was influenced by an operative time of more than
360 minutes (p ⫽ 0.0285), blood loss of more than 400
mL (p ⫽ 0.0104), and serum albumin levels of less than 3.5
g/dL (p ⫽ 0.0047).
Postoperative incision care
When a surgical incision was primarily closed, the incision
was usually covered with a sterile dressing for 48 hours.
After 48 hours, the incision was left uncovered.
Statistics
Logistic regression multivariate analysis was performed to
determine the predictive value of the risk factors. Significance was defined as a p value ⬍ 0.05. Statistical analyses
were performed using StatView 5.0 for Windows (SAS Institute Inc).
RESULTS
The median operative time during 2001 to 2008 was 345.5
minutes, and the median operative time of each year is
shown in Figure 2. The median blood loss during 2001 to
2008 was 360 mL and the median operative blood loss
during each year is shown in Figure 3. The rate of red blood
cell transfusion was 6.8%. The morbidity rate was 15.6%,
caused by the rising rates of pleural effusion (5.7%), ascites
(2.9%), hemoperitoneum (2.2%), bile leakage and intraabdominal abscess (6.7%), and wound infection (2.4%)
(Table 3). Pneumonia, urinary tract infection, cardiac complications, renal insufficiency and failure, deep vein thrombosis, and pulmonary embolism were not included in com-
DISCUSSION
The independent relative risk for morbidity was influenced
by an operative time of more than 360 minutes, blood loss
of more than 400 mL, and serum albumin levels of less
than 3.5 g/dL, as determined using multivariate logistic
regression analysis. Although hepatectomy is generally a
complex operation, a shorter operative time and reduced
blood loss were obtained by improving the surgical technique with new devices and intraoperative management,
including anesthesia. In addition to these efforts, decision
making using our algorithm and perioperative management according to the CDC guidelines also reduced the
morbidity and mortality associated with hepatectomy. The
outcomes of our series were equal or superior to the outcomes of a large series including more than 600 patients.19
The length of postoperative hospital stay (18.4 days) was
equal to that in another Japanese center.18
Recently criteria, including include ICGR15, have become
reliable to determine the indication for hepatectomy,6,7 especially the criteria of Makuuchi, which are widely used in Japan
Vol. 211, No. 4, October 2010
Kamiyama et al
Perioperative Management of Hepatectomy
447
Table 3. Postoperative Complications
Year
Patients
n
2001
2002
2003
2004
2005
2006
2007
2008
Total
95
80
103
94
101
112
102
106
793
Pleural
effusion
n
%
3
8
15
2
5
5
1
6
457
3.22
10.0
14.6
2.1
5.0
4.5
1.0
5.7
5.7
Ascites
n
%
6
4
2
2
1
2
2
3
229
Bleeding
n
%
6.3
5.0
1.9
2.1
1.0
1.8
2.0
2.8
2.9
3
3
2
4
2
1
2
0
17
3.2
3.8
1.9
4.3
2.0
0.9
2.0
0
2.2
and determine the operative procedure. Conversely, although
the Child-Pugh classification system has been applied worldwide to evaluate the functional reserve of the liver in patients with chronic liver disease,20 the resectable volume is
not determined by this system. Our algorithm, which was
classified by ICGR15, had no limitations according to the
bilirubin level and regulated the volume of liver to be resected, in contrast with Makuuchi’s criteria. In Makuuchi’s
criteria, patients with a total bilirubin level greater than 1.1
mg/dL undergo a limited resection with enucleation. However, in our series, 78 (64.5%) of 121 patients with a total
bilirubin level over 1.1 mg/dL underwent hepatectomy in
which the resected liver volume was more than segmentectomy, and the rate of postoperative hepatic failure was only
0.1% (1 of 793). Therefore, our algorithm was supposed to
be reasonable for selection of the appropriate operative procedures in patients with impaired liver functional reserves.
Moreover, as indications for PTPE were incorporated into
Table 4. Logistic Regression Multivariate Analysis of the
Risk Factors for Postoperative Complications
Risk factor
Gender, male
Age ⬍65 y
Operation time ⬎360 min
Blood loss ⬎400 mL
Albumin ⬍3.5 g/dL
Total bilirubin ⬍0.7 mg/dL
ICGR15 ⬍15%
HBV(⫺)HCV(⫺)
Minor resection
Child-Pugh class B
Re-resection, yes
p
Value
Odds
ratio
95% CI
0.8397
0.3135
0.0285
0.0104
0.0047
0.3337
0.3024
0.6718
0.3354
0.8739
0.6591
1.047
0.803
1.650
1.761
3.195
0.817
1.304
0.912
1.279
0.875
1.164
0.669–1.639
0.524–1.230
1.054–2.584
1.143–2.710
1.429–7.143
0.542–1.232
0.787–2.160
0.596–1.397
0.775–2.110
0.168–4.545
0.593–2.283
HBV, hepatitis B virus surface antigen; HCV, hepatitis C virus antibody;
ICGR15, indocyanine green retention rate at 15 minutes.
Reoperation
after bleeding
n
%
2
0
0
0
0
1
1
0
4
2.1
0
0
0
0
0.9
1.0
0
0.5
Bile
leakage/
abscess
n
%
Reoperation
after bile
leakage/
abscess
n
%
Wound
infection
n
%
8
7
9
6
2
10
4
7
53
4
3
4
2
0
1
0
1
159
2
3
2
2
3
2
2
3
19
8.4
8.8
8.7
6.4
2.0
8.9
3.9
6.6
6.7
4.2
3.8
3.9
2.1
0
0.9
0
0.9
1.9
2.1
3.8
1.9
2.1
3.0
1.8
2.0
2.8
2.4
our algorithm, it was considered more useful in determining the appropriate operative procedure. When the effective resection ratio was more than 60%, PTPE was indicated in patients whose ICGR15 was less than 15%. This
indication for PTPE was the same as that described by
Imamura and colleagues,21 although they indicated PTPE
for patients in whom the remaining liver volume ratio after
hepatectomy was less than 40% using Makuuchi’s criteria.
3D-CT achieved a higher spatial and temporal resolution of orthogonal images and produced multiplanar reformation of images. Because 3D-CT clearly revealed the
position of the tumor and vessels, almost to a similar extent
as observed in vivo, preoperative simulation of the surgical
procedure was easier and more accurate. 3D-CT was useful
to understand the correlation between vessels and tumor
and for preoperative simulations, particularly in patients
with large tumors or vascular anomalies.22 Because the hepatic segment, sector, or lobe in which the tumor to be
resected was located, and the hepatic artery and portal vein
were well understood by the surgeons, hepatic parenchyma
with no inflow was completely resected.
We resected hepatic parenchyma using the hook spatula
of a harmonic scalpel combined with bipolar cautery and a
saline irrigation system or DS3.0. On the basis of our observations, the outer nonsharp radius of the hook spatula is particularly useful for dissecting the soft liver parenchyma because it offers slightly less cutting power than the inner sharp
radius or Cavitron ultrasonic surgical aspirator (CUSA).
Vessels that were firmer than the liver parenchyma could be
easily exposed using the outer nonsharp radius when their
diameter was greater than approximately 2 mm. In our
opinion, this device is more suitable for liver dissection
than CUSA or dissecting forceps, not only for experienced
surgeons, but also for inexperienced surgeons. Conversely,
bipolar cautery with a saline irrigation system combined
448
Kamiyama et al
Perioperative Management of Hepatectomy
with CUSA23 or the hook spatula of the harmonic scalpel24
are useful for dissection of the hepatic parenchyma without
inflow occlusion. Because the harmonic scalpel needs an
extended period of time to achieve adequate hemostasis, we
obtained certain and convenient coagulation using bipolar
cautery with a saline irrigation system and DS3.0. DS3.0
uses radiofrequency energy that accumulates at the tip of
the device and is transmitted to the liver tissue via the saline
solution flowing from the tip at a low rate (1 drop/second)
through a channel provided inside the device. Therefore,
DS3.0 induces tissue coagulation to a wider area and
readily coagulates vessels and Glisson’s sheaths with a diameter of less than 2 mm. The combination of the hook
spatula of the harmonic scalpel and bipolar cautery with a
saline irrigation system or DS3.0 is useful to decrease operative blood loss and shorten the operative time.
In this study, we examined the relationship between
complications and clinical factors. Multivariate analysis revealed that a longer operative time and increased blood loss
were significantly related to postoperative complications.
The quantity of blood loss and blood transfusion adversely
affect the outcomes of patients.25,26 Massive blood loss and
the associated blood transfusion correlate with morbidity
after hepatic resection.21 An immunosuppressive state is
induced by transfusion of red blood cells in patients undergoing an operation, and this state can increase the risk of
postoperative infections27 and tumor recurrence.28 In our
series, the median blood loss from 2001 to 2008 was 360
mL and the transfusion rate was 6.8%, which was equal to
data from a previous report.21 This low amount of blood
loss and rate of transfusion were achieved by using a harmonic scalpel and coagulating device (bipolar cautery or
DS 3.0), low central venous pressure during the operation,29 intermittent inflow occlusion, etc. Conversely, it is
well established that the longer the wound is open the
higher is the risk for surgical site infection.30 It has been
reported that hospitals in the outlier category for surgical
site infection have a shorter mean duration of operation,
significantly reduced incidence of other complications, and
reduced mortality.31 Although the Hokkaido University
Hospital is a teaching hospital and hepatectomy is generally a complex operation, the operative time was gradually
shortened by improving the surgical technique with new
devices and intraoperative management, including anesthesia. As a result of these efforts, postoperative complications involving surgical site infection were very infrequent.
Bile leakage is a major complication after hepatic resection because the presence of bile in a dead space may provide an ideal environment for bacterial growth and become
an intra-abdominal abscess.32 Intraoperative cholangiography was routinely performed to confirm the branch of the
J Am Coll Surg
bile duct to be preserved and to detect insufficiently closed
stumps of the bile ducts as a bile leakage test, although it is
reported that there is no advantage in using a bile leakage
test during hepatic resection.18 Since 2005, if leakage of the
contrast medium or an air bubble was observed, we used a
C-tube, which was easily removable, inserted into the cystic
duct to decompress the bile duct. The number of reoperations for bile leakage gradually decreased to between 0 and
1 from 2005 to 2008. For this reason, decompression of the
bile duct with a C-tube is suggested as an effective technique to prevent a massive bile leakage. Moreover, because
operative procedures in which the cut surface exposes the
major Glisson’s sheath and includes the hepatic hilum are
high-risk procedures,33 decompression using a C-tube is
also suggested to be useful for this procedure.
In conclusion, a shorter operative time and reduced
blood loss were obtained by improving the surgical technique using new devices and intraoperative management,
including anesthesia. Moreover, decision making using our
algorithm and perioperative management according to the
CDC guidelines contributed to a reduction in the morbidity and mortality associated with hepatectomy.
Author Contributions
Study conception and design: Kamiyama
Acquisition of data: Nakanishi, Yokoo, Tahara, Yamashita,
Shimamura, Matsushita
Analysis and interpretation of data: Kamiyama, Kamachi,
Taniguchi
Drafting of manuscript: Kamiyama, Todo
Critical revision: Todo
Acknowledgment: The authors wish to thank the staff of
General Surgery, Graduate School of Medicine, Hokkaido
University, for their kind cooperation.
REFERENCES
1. Arii S, Yamaoka Y, Futagawa S, et al. Results of surgical and nonsurgical treatment for small-sized hepatocellular carcinomas: a retrospective and nationwide survey in Japan. The Liver Cancer Study
Group of Japan. Hepatology 2000;32:1224–1229.
2. Poon RT, Fan ST, Ng IO, et al. Significance of resection margin
in hepatectomy for hepatocellular carcinoma: A critical reappraisal. Ann Surg 2000;231:544–551.
3. Ikai I, Arii S, Ichida T, et al. Report of the 16th follow-up survey
of primary liver cancer. Hepatol Res 2005;32:163–172.
4. Tobe T. Hepatectomy in patients with cirrhotic liver: clinical
and basic observation. Surg Annu 1984;121:515–521.
5. Moser MA, Kneteman NM, Minuk GY. Research toward safer
resection of the cirrhotic liver. HPB Surg 2000;11:285–297.
6. Yamanaka N, Okamoto E, Oriyama T, et al. A prediction
scoring system to select the surgical treatment of liver cancer.
Vol. 211, No. 4, October 2010
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Kamiyama et al
Further refinement based on 10 years of use. Ann Surg
1994;219:342–346.
Makuuchi M, Kosuge T, Takayama T, et al. Surgery for small
liver cancers. Semin Surg Oncol 1993;9:298–304.
Nimura Y. Extended surgery in bilio-pancreatic cancer: the Japanese experience. Semin Oncol 2002;29:17–22.
Todo S, Furukawa H; Japanese Study Group on Organ Transplantation. Living donor liver transplantation for adult patients
with hepatocellular carcinoma: experience in Japan. Ann Surg
2004;240:451–459.
Adam R, Bismuth H, Castaing D, et al. Repeat hepatectomy for
colorectal liver metastases. Ann Surg 1997;225:51–60.
Hashikura Y, Ichida T, Umeshita K, et al. Donor complications
associated with living donor liver transplantation in Japan.
Transplantation 2009;88:110–114.
Surman OS, Hertl M. Liver donation: donor safety comes first.
Lancet 2003;362:674–675.
Yanaga K, Kanematsu T, Takenaka K, et al. Intraperitoneal
septic complications after hepatectomy. Ann Surg 1986;203:
148–152.
Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control
and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97–132.
Kawamura H, Kamiyama T, Nakagawa T, et al. Preoperative
evaluation of hepatic functional reserve by converted ICGR15
calculated from Tc-GSA scintigraphy. J Gastroenterol Hepatol
2008;23:1235–1241.
Onodera Y, Omatsu T, Nakayama T, et al. Peripheral anatomic
evaluation using 3D CT hepatic venography in donors: Significance of peripheral venous visualization in living-donor liver
transplantation. AJR 2004;183:1065–1070.
Ogasawara K, Une Y, Nakajima Y, et al. The significance of
measuring liver volume using computed tomographic images
before and after hepatectomy. Surg Today 1995;25:43–48.
Ijichi M, Takayama T, Toyoda H, et al. Randomized trial of the
usefulness of a bile leakage test during hepatic resection. Arch
Surg 2000;135:1395–1400.
Asiyanbola B, Chang D, Gleisner AL, et al. Operative mortality
after hepatic resection: are literature-based rates broadly applicable? J Gastrointest Surg 2008;12:842–851.
Mansour A, Watson W, Shayani V, et al. Abdominal operations
in patients with cirrhosis: still a major surgical challenge. Surgery 1997;122:730–735.
Perioperative Management of Hepatectomy
449
21. Imamura H, Seyama Y, Kokudo N, et al. One thousand fifty-six
hepatectomies without mortality in 8 years. Arch Surg 2003;
138:1198–1206.
22. Kamiyama T, Nakagawa T, Nakanishi K, et al. Preoperative evaluation of hepatic vasculature by three-dimensional computed
tomography in patients undergoing hepatectomy. World J Surg
2006;30:400–409.
23. Yamamoto Y, Ikai I, Kume M, et al. New simple technique for
hepatic parenchymal resection using a Cavitron Ultrasonic Surgical Aspirator and bipolar cautery equipped with a channel for
water dripping. World J Surg 1999;23:1032–1037.
24. Kamiyama T, Kurauchi N, Nakagawa T, et al. Laparoscopic
hepatectomy with the hook blade of ultrasonic coagulating
shears and bipolar cautery with a saline irrigation system.
J Hepatobiliary Pancreat Surg 2005;12:49–54.
25. Jamieson GG, Corbel L, Campion JP, et al. Major liver resection
without a blood transfusion: is it a realistic objective? Surgery
1992;112:32–36.
26. Nagorney DM, van Heerden JA, Ilstrup DM, et al. Primary
hepatic malignancy: surgical management and determinants of
survival. Surgery 1989;106:740–748.
27. Greenburg AG. Benefits and risks of blood transfusion in surgical patients. World J Surg 1996;20:1189–1193.
28. Yamamoto J, Kosuge T, Takayama T, et al. Perioperative blood
transfusion promotes recurrence of hepatocellular carcinoma after hepatectomy. Surgery 1994;115:303–309.
29. Jones RM, Moulton CE, Hardy KJ. Central venous pressure and
its effect on blood loss during liver resection. Br J Surg 1998;85:
1058–1060.
30. Khuri SF, Najjar SF, Daley J, et al. Comparison of surgical outcomes between teaching and nonteaching hospitals in the Department of Veterans Affairs. Ann Surg 001;234:370–382.
31. Campbell DA Jr, Henderson WG, Englesbe MJ, et al. Surgical site infection prevention: the importance of operative
duration and blood transfusion–results of the first American
College of Surgeons-National Surgical Quality Improvement
Program Best Practices Initiative. J Am Coll Surg 2008;207:
810–820.
32. Andersson R, Tranberg KG, Bengmark S. Roles of bile and bacteria in biliary peritonitis. Br J Surg 1990;77:36–39.
33. Yamashita Y, Hamatsu T, Rikimaru T, et al. Bile leakage after
hepatic resection. Ann Surg 2001;233:45–50.