Intraoperative Hyperglycemia during Liver Resection: Predictors and Association with the Extent of Hepatocytes Injury

<div><p>Background</p><p>Patients undergoing liver resection are at risk for intraoperative hyperglycemia and acute hyperglycemia is known to induce hepatocytes injury. Thus, we aimed to evaluate whether intraoperative hyperglycemia during liver resection is associated with the extent of hepatic injury.</p><p>Methods</p><p>This 1 year retrospective observation consecutively enrolled 85 patients undergoing liver resection for hepatocellular carcinoma. Blood glucose concentrations were measured at predetermined time points including every start/end of intermittent hepatic inflow occlusion (IHIO) <i>via</i> arterial blood analysis. Postoperative transaminase concentrations were used as surrogate parameters indicating the extent of surgery-related acute hepatocytes injury.</p><p>Results</p><p>Thirty (35.5%) patients developed hyperglycemia (blood glucose > 180 mg/dl) during surgery. Prolonged (≥ 3 rounds) IHIO (odds ratio [OR] 7.34, <i>P</i> = 0.004) was determined as a risk factors for hyperglycemia as well as cirrhosis (OR 4.07, <i>P</i> = 0.022), lower prothrombin time (OR 0.01, <i>P</i> = 0.025), and greater total cholesterol level (OR 1.04, <i>P</i> = 0.003). Hyperglycemia was independently associated with perioperative increase in transaminase concentrations (aspartate transaminase, β 105.1, standard error 41.7, <i>P</i> = 0.014; alanine transaminase, β 81.6, standard error 38.1, <i>P</i> = 0.035). Of note, blood glucose > 160 or 140 mg/dl was not associated with postoperative transaminase concentrations.</p><p>Conclusions</p><p>Hyperglycemia during liver resection might be associated with the extent of hepatocytes injury. It would be rational to maintain blood glucose concentration < 180 mg/dl throughout the surgery in consideration of parenchymal disease, coagulation status, lipid profile, and the cumulative hepatic ischemia in patients undergoing liver resection for hepatocellular carcinoma.</p></div

Preoperative and intraoperative clinical data of liver transplant recipients.

<p>Data are described as median (IQR, range) or number.</p><p>*Based on the tricuspid regurgitant jet.</p><p>†Measured via blood sampling.</p><p>‡Including Hartman's solution, plasma solution, dextrose solution, normal saline, and half saline.</p><p>Preoperative and intraoperative clinical data of liver transplant recipients.</p

The Bland-Altman plot shows wide 95% limits of agreement between bioreactance and thermodilution in cardiac output (CO).

<p>The Bland-Altman plot shows wide 95% limits of agreement between bioreactance and thermodilution in cardiac output (CO).</p

Significant difference in perioperative increase of AST (‘x’ mark) and ALT (‘o’ mark) according to the occurrence of intraoperative hyperglycemia (HG).

<p>Significant difference in perioperative increase of AST (‘x’ mark) and ALT (‘o’ mark) according to the occurrence of intraoperative hyperglycemia (HG).</p

Up-and-down blood glucose fluctuation in response to clamping (C) and unclamping (U) of intermittent hepatic inflow occlusion (IHIO). I, anesthetic induction.

<p>Up-and-down blood glucose fluctuation in response to clamping (C) and unclamping (U) of intermittent hepatic inflow occlusion (IHIO). I, anesthetic induction.</p

The Bland-Altman plot shows wide 95% limits of agreement between bioreactance and thermodilution in cardiac output (CO) during the dissection (A), anhepatic (B), and reperfusion phase (C).

<p>The Bland-Altman plot shows wide 95% limits of agreement between bioreactance and thermodilution in cardiac output (CO) during the dissection (A), anhepatic (B), and reperfusion phase (C).</p

Probability of intraoperative hyperglycemia in relation to the increase in prothrombin time internationalized ratio and serum total cholesterol concentration.

<p>Probability of intraoperative hyperglycemia in relation to the increase in prothrombin time internationalized ratio and serum total cholesterol concentration.</p

Four-quadrant concordance analysis between the changes in cardiac output (CO) measured by bioreactance and thermodilution.

<p>The zero-centered square corresponds to the 15% exclusion zone.</p

Interaction between serum bilirubin and age.

<p>The impact of lower serum bilirubin on the development of intraoperative hyperglycemia is stronger in old donors (>40 years) than in younger donors.</p

Multivariate analysis for intraoperative hyperglycemia during liver resection.

<p>Due to concern of multicollinearity prothrombin time and total cholesterol level were separately enrolled into the multivariate model. Odds ratio and P values of other variables were described based on the model with prothrombin time internationalized ratio (INR).</p><p>Multivariate analysis for intraoperative hyperglycemia during liver resection.</p