Strategies to decrease bleeding and biliary fistula

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Strategies to decrease

bleeding and biliary ﬁstula

during and a3er liver resec5on

Pr Olivier Detry

Department of Abdominal Surgery & Transplanta5on CHU Liège, Université de Liège

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Disclosure statement

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Liver

•  _{Responsible
for
synthesis
of
coagula5on
and} ﬁbrinolyic factors

•  _{Major
blood
vessels} •  Synthesis of bile

•  _{Per/post
opera5ve
blood
loss
and
biliary}

ﬁstula are major causes of morbidity of liver surgery

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Facts: Blood loss

•  _{Per
&
postopera5ve
hemorrhage}

transfusion rate 5-‐20% / return to OR increased risk: in major resec5ons

in steato5c / chemo livers in cirrho5c livers

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Facts: biliary ﬁstula

•  Postopera5ve biliary ﬁstula 1-‐15% increased if resistance to bile ﬂow

increased in non anatomical resec5on increased in large resec5on plane

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Preopera5vely

•  _{Good
surgical
planning
and
experience} •  _{Good
knowledge
of
liver
anatomy}

•  _{Evalua5on
of
the
risks
of
postopera5ve
liver} dysfunc5on

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Peropera5vely

•  Limita5on of the blood loss -‐ low venous pressure

-‐ hilar clamping (total/hemi) •  Laparotomy/laparoscopy

•  Liver 5ssue sec5on devices -‐ CUSA/US/radiofrequency

•  Control of the vessels and bile ducts -‐ liga5on/clips/endoGIA

•  Coagula5on devices

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End of resec5on

•  _{Manual
compression
of
the
resec5on
plane} with gauze (up to 15 min!)

•  _{Therapeu5c:
Surgicel
/
Gelfoam
/
Tachosil} •  _{Preven5ve:
?}

ﬁbrin sealent ? •  _Drain?

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Liver surgery in Jehovah witnesses

•  _EPO •  _Iron

•  _{Liver
transplanta5on:} -‐ spleen embolisa5on

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Peropera5vely

•  Limita5on of the blood loss -‐ low venous pressure

-‐ hilar clamping (total/hemi) •  Laparotomy/laparoscopy

•  Liver 5ssue sec5on device -‐ CUSA/US/radiofrequency

•  Control of the vessels and bile ducts -‐ liga5on/clips/endoGIA

•  Coagula5on device

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End of resec5on

•  _{Manual
compression
of
the
resec5on
plane} with gauze (up to 15 min!)

•  _{Therapeu5c
Surgicel/Gelfoam/Tachosil} •  _Preven5ve

ﬁbrin sealent ?

•  _{Cholangiography
contrast/methylene
blue/air} •  Drain?

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