1. How to conclude a right hepatectomy Sorina Cornateanu Maximilliano Gelli CHB-Hopital Paul-Brousse ACHBT Jeunes, 14.09.2012, Rouen

2. Introduction Schneider, Am Coll Surg 2012 (in press) John Hopkins Hospital Database (1986 – 2005) 9957 pt Complication rate 34.9% - Postoperative hemorrhage 3.2% - Blood transfusion 11.5% - Re-operation 5.2% - Postoperative infection 2.3% Gastrointestinal complications 6.3% Cardiac complications 3.2% Mortality 7.3% Mortality according to the type of liver resection: 1. extended right hepatectomy 8.7% 2. right hepatectomy 6.6% … Segmentectomy 1.8%

3. « Standard » procedure Fixation of remnant liver Doppler US control Portal inflow evaluation Hemostatic break Methilen blue dye test Biological glue Drainage Continuous wound analgesic instillation

4. Remnant liver rotation Poon, Hepatogastroenterology 1998 Belghiti, Br J Surg 1992 Impairment of venous outflow could be underestimated after right liver resection Fixing the liver whether the triangular ligament has been divided or not and whatever the extent of the right hepatectomy Ogata, Br J Surg 2005

5. Remnant liver rotation Wang, J Gastrointest Surg 2010 Di Domenico, Abdomin Imaging 2012 Macroscopic hepatic venous congestion Biological cholestasis Jaundice, Ascites Lower extremity oedema

6. Control of vascular elements by US Left and Middle Hepatic Vein - Doppler trifasic waveforms in both HVs - Good velocity - Absence of HV thrombus High risk: exposure of HV > 3 cm along transection plane Arita, Surgery 2007 Left Portal Vein - Portal flow direction and velocity -Regular laminary flow Left branch of Hepatic Artery - Systolic peak Advantages: Readily available and inexpensive tool Fast Reproducible Objective data ++

7. Intraoperative CEUS

8. Portal inflow evaluation Transplantation Portal hyperperfusion is correlated with poor postoperative outcomes: - SFSS - Vascular complications - Graft regeneration impairment Troisi, Ann Surg 2003 Eguchi, Liver Transp 2003 Fan, Liver Transp 2011 Hori, Transp 2012 Portal Flow Modulation - PF > 250 ml/100 gr GW - PP > 20 mmHg Different procedures: -Splenic Artery ligation/embolization -Splenectomy - Portosystemicshunts PP < 15 mmHg

9. 277 patients Paul Brousse Postoperative liver failure Post hepatectomy Portal Pressure Probability of Post-Hepatectomy Liver Failure ≥ 16 mmHg8% ≥ 18 mmHg11% ≥ 20 mmHg14% ≥ 22 mmHg16% ≥ 26 mmHg20% ≥ 30 mmHg27% ≥ 34 mmHg36% Allard MA, Vibert E. et al. Submitted

10. Oncological surgery SOS and CASH increase morbidity and liver failure Prolonged preoperative chemotherapy increases the risk of hepatic injury and morbidity Narita, Surg Today 2011 Karoui, Ann Surg 2006 Chun, Lancet Oncol 2009 Portal inflow evaluation Experimental data Michaloupulos, AJP 2010 Marubashy Surgery 2004

11. Portal inflow evaluation Oncological surgery Cirrhotic liverTransplantation Experimental Data

12. Hemostatic Break …No scientific data

13. Key points: 1. biliary leakage 2. symptomatic fluid collections But.. 3. ascending intraabdominal infection Abdominal drainage

14. 4 RCT in elective liver surgery Abdominal drainage - sample size and incidence of events - definition of biliary fistula and leakage - duration of drainage < 7 POD Limits

15. Abdominal drainage Makuuchi, J Hepatobiliary Pancreat Sci 2010 Routine and systematic protocol of drainage management ComplicationsRetention or Drainage salvage technique Percutaneous procedure Reoperation Biliary leakage 8.6 % 77 %10 %12 % Fluid collection 5.1 % 31 %38 %31 %

16. Abdominal drainage Tanaka, Surg Today 2012 Biliary concentration drainage Biliary concentration serum X Volume of drainage fluid at POD 2 < 200 Ablation at POD 2 > 200 Ablation at POD 4

17. Continuous wound analgesic instillation Chan, Anesthesia 2010

18. Conclusions Systematic Fixation of remnant liverYES Doppler US controlYES Portal inflow evaluationYES Hemostatic break??? Drainage??? Continuous wound analgesic instillationYES

19. Thank you…