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Safety and feasibility of phlebotomy with controlled hypovolemia to prevent blood loss in major hepatic resections
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Electronic Poster Abstracts
Methods: A retrospective review of forty patients undergoing surgery for hepato-pancreato-biliary disease during March 2010 to August 2012 was conducted. Body fluid compositions were measured using BIA on preoperative day, immediate postoperative day and postoperative day 1. Fluid balance was recorded during operation and until postoperative day 1. Using the estimated net fluid balance, patients were divided into two groups. Balanced group included patients with net fluid balance within 500mL and patients with net fluid balance in excess of 500mL belonged to imbalanced group. Results of the BIA were compared. Results: 16 patients were in balanced group and 24 patients were in imbalanced group. The mean fluid balances were 231.42 38.86mL for balanced group and 1226.99 136.09mL for imbalanced group. Total body water (p = 0.091), extracellular water (p = 0.125), ECW/TBW (p = 0.156) and intracellular water (p = 0.173) showed no significant changes in the balanced group. In the imbalanced group, while TBW (p = 0.057) did not have a significant change, ECW (p = 0.001), ECW/TBW (p = 0.018), and ICW (p = 0.024) showed significant increase between preoperative and postoperative day. Conclusion: BIA was found to be an effective noninvasive method for assessing the changes in body fluid compositions of fluid imbalanced patients.
EP01C-020 SAFETY AND FEASIBILITY OF PHLEBOTOMY WITH CONTROLLED HYPOVOLEMIA TO PREVENT BLOOD LOSS IN MAJOR HEPATIC RESECTIONS G. Martel1,2, C. Wherrett3, J. Rekman1, S. Saeed2, K. Lemon1, R. Mimeault1 and F. Balaa1 1 Department of Surgery, University of Ottawa, 2Clinical Epidemiology Program, Ottawa Hospital Research Institute, and 3Department of Anesthesiology, University of Ottawa, Canada Background: Blood loss in liver surgery is a key determinant of outcome. Whole blood phlebotomy, a simple intervention that differs from acute normovolemic hemodilution, aims to decrease blood loss during liver resection by lowering central venous pressure (CVP) and creating a state of controlled hypovolemia. The objective of this work was to review our preliminary experience with this novel technique for safety, feasibility, and effectiveness. Methods: Patients who underwent liver resection and phlebotomy were followed prospectively (2013e 2015). Exclusion criteria were defined a priori. Phlebotomy was targeted to patients’ weight (7e10 mL/ kg) shortly before parenchymal transection. The withdrawn blood was not replaced by crystalloid or colloid, and low CVP anesthesia was used. Following parenchymal transection, the blood was given back to the patient. Results: 16 patients underwent major liver resection with phlebotomy, of which 69% had metastatic disease. A median of 7.3 mL/kg (5.3e10.1) of blood was phlebotomized. The
median operative blood loss was 375 mL (range 130e2,000) or a median of 4.7 mL/kg. Two patients required an additional allogeneic perioperative blood transfusion, totalling 3 transfused units. The median peak postoperative creatinine was 89.5 mmol/L (1.02 mg/dL). One patient had a grade 3a complication and there was no mortality. Conclusions: Whole blood phlebotomy with controlled hypovolemia prior to major liver resection appears safe and feasible. In this preliminary series, phlebotomy also appeared effective at reducing blood loss and blood transfusion when compared to published cohorts. This technique warrants further comparative study, particularly where other blood conservation methods are controlled for.
EP01C-021 PERIOPERATIVE OUTCOMES OF LAPAROSCOPIC VERSUS OPEN RADIOFREQUENCY ABLATION FOR THE PRIMARY TREATMENT OF HEPATIC MALIGNANCIES: A POPULATION-BASED APPRAISAL D. Sanford1, W. Hawkins2 and R. Fields2 1 Washington University School of Medicine in St. Louis, and 2Hepatobiliary, Pancreatic, & Gastrointestinal Surgery, Washington University School of Medicine in St. Louis, United States Introduction: Radiofrequency ablation (RFA) is an effective treatment in appropriately selected patients with primary and metastatic cancer in the liver. We sought to compare the perioperative outcomes of patients undergoing open versus laparoscopic RFA of primary and metastatic liver tumors. Methods: We examined patients in the Nationwide Inpatient Sample from 2006e2011 undergoing to RFA as the primary admission procedure, excluding patients who underwent combined gastrointestinal or liver resection resections and percutaneous RFA. Logistic regression, linear regression, and 1:1 propensity score matching were employed to examine the influence of an open versus laparoscopic approach on postoperative outcomes. Results: 1145 patients underwent RFA for primary or metastatic liver cancer: 508 (44.4%) open and 637 (55.6%) laparoscopic. On multivariate analysis, the laparoscopic approach was independently associated with decreased postoperative complications (OR = 0.51, p < 0.001), blood transfusions (OR = 0.35, p < 0.001)), length of stay (net difference = e 3.4 days, p < 0.001), and total hospital charges (net difference = e $27,877, p < 0.001). In the 1:1 propensity score-matched analysis (n = 814 patients), compared to patients who underwent open RFA, patients who underwent laparoscopic RFA had a complication rate of 12.8% versus 22.1%(p < 0.001), a transfusion rate of 5.2% vs 13.5%(p < 0.001), a length of stay of 2.9 vs 6.0 days (p < 0.001), and total hospital charges of $51,270 vs $73,771 (p < 0.001). Conclusion: In this population-based study, laparoscopic RFA appears safe and may have improved short term perioperative outcomes compared to open RFA. Further study is needed to determine if this association is causal as well as to study the long term oncologic outcomes.
HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts
Methods: A retrospective review of forty patients undergoing surgery for hepato-pancreato-biliary disease during March 2010 to August 2012 was conducted. Body fluid compositions were measured using BIA on preoperative day, immediate postoperative day and postoperative day 1. Fluid balance was recorded during operation and until postoperative day 1. Using the estimated net fluid balance, patients were divided into two groups. Balanced group included patients with net fluid balance within 500mL and patients with net fluid balance in excess of 500mL belonged to imbalanced group. Results of the BIA were compared. Results: 16 patients were in balanced group and 24 patients were in imbalanced group. The mean fluid balances were 231.42 38.86mL for balanced group and 1226.99 136.09mL for imbalanced group. Total body water (p = 0.091), extracellular water (p = 0.125), ECW/TBW (p = 0.156) and intracellular water (p = 0.173) showed no significant changes in the balanced group. In the imbalanced group, while TBW (p = 0.057) did not have a significant change, ECW (p = 0.001), ECW/TBW (p = 0.018), and ICW (p = 0.024) showed significant increase between preoperative and postoperative day. Conclusion: BIA was found to be an effective noninvasive method for assessing the changes in body fluid compositions of fluid imbalanced patients.
EP01C-020 SAFETY AND FEASIBILITY OF PHLEBOTOMY WITH CONTROLLED HYPOVOLEMIA TO PREVENT BLOOD LOSS IN MAJOR HEPATIC RESECTIONS G. Martel1,2, C. Wherrett3, J. Rekman1, S. Saeed2, K. Lemon1, R. Mimeault1 and F. Balaa1 1 Department of Surgery, University of Ottawa, 2Clinical Epidemiology Program, Ottawa Hospital Research Institute, and 3Department of Anesthesiology, University of Ottawa, Canada Background: Blood loss in liver surgery is a key determinant of outcome. Whole blood phlebotomy, a simple intervention that differs from acute normovolemic hemodilution, aims to decrease blood loss during liver resection by lowering central venous pressure (CVP) and creating a state of controlled hypovolemia. The objective of this work was to review our preliminary experience with this novel technique for safety, feasibility, and effectiveness. Methods: Patients who underwent liver resection and phlebotomy were followed prospectively (2013e 2015). Exclusion criteria were defined a priori. Phlebotomy was targeted to patients’ weight (7e10 mL/ kg) shortly before parenchymal transection. The withdrawn blood was not replaced by crystalloid or colloid, and low CVP anesthesia was used. Following parenchymal transection, the blood was given back to the patient. Results: 16 patients underwent major liver resection with phlebotomy, of which 69% had metastatic disease. A median of 7.3 mL/kg (5.3e10.1) of blood was phlebotomized. The
median operative blood loss was 375 mL (range 130e2,000) or a median of 4.7 mL/kg. Two patients required an additional allogeneic perioperative blood transfusion, totalling 3 transfused units. The median peak postoperative creatinine was 89.5 mmol/L (1.02 mg/dL). One patient had a grade 3a complication and there was no mortality. Conclusions: Whole blood phlebotomy with controlled hypovolemia prior to major liver resection appears safe and feasible. In this preliminary series, phlebotomy also appeared effective at reducing blood loss and blood transfusion when compared to published cohorts. This technique warrants further comparative study, particularly where other blood conservation methods are controlled for.
EP01C-021 PERIOPERATIVE OUTCOMES OF LAPAROSCOPIC VERSUS OPEN RADIOFREQUENCY ABLATION FOR THE PRIMARY TREATMENT OF HEPATIC MALIGNANCIES: A POPULATION-BASED APPRAISAL D. Sanford1, W. Hawkins2 and R. Fields2 1 Washington University School of Medicine in St. Louis, and 2Hepatobiliary, Pancreatic, & Gastrointestinal Surgery, Washington University School of Medicine in St. Louis, United States Introduction: Radiofrequency ablation (RFA) is an effective treatment in appropriately selected patients with primary and metastatic cancer in the liver. We sought to compare the perioperative outcomes of patients undergoing open versus laparoscopic RFA of primary and metastatic liver tumors. Methods: We examined patients in the Nationwide Inpatient Sample from 2006e2011 undergoing to RFA as the primary admission procedure, excluding patients who underwent combined gastrointestinal or liver resection resections and percutaneous RFA. Logistic regression, linear regression, and 1:1 propensity score matching were employed to examine the influence of an open versus laparoscopic approach on postoperative outcomes. Results: 1145 patients underwent RFA for primary or metastatic liver cancer: 508 (44.4%) open and 637 (55.6%) laparoscopic. On multivariate analysis, the laparoscopic approach was independently associated with decreased postoperative complications (OR = 0.51, p < 0.001), blood transfusions (OR = 0.35, p < 0.001)), length of stay (net difference = e 3.4 days, p < 0.001), and total hospital charges (net difference = e $27,877, p < 0.001). In the 1:1 propensity score-matched analysis (n = 814 patients), compared to patients who underwent open RFA, patients who underwent laparoscopic RFA had a complication rate of 12.8% versus 22.1%(p < 0.001), a transfusion rate of 5.2% vs 13.5%(p < 0.001), a length of stay of 2.9 vs 6.0 days (p < 0.001), and total hospital charges of $51,270 vs $73,771 (p < 0.001). Conclusion: In this population-based study, laparoscopic RFA appears safe and may have improved short term perioperative outcomes compared to open RFA. Further study is needed to determine if this association is causal as well as to study the long term oncologic outcomes.
HPB 2016, 18 (S1), e1ee384