Although other reports have stressed the inevitability of portal hypertension and splanchnic pooling following major liver resections, clinical observations during 30 major hepatic resections and measurements of portal pressure in three consecutive trisegmentectomies fail to support this contention. If the remaining liver is normal and careful anatomic dissection is used, major resections can be performed without inducing portal hypertension

Buerk, CA

Putnam, CW

Starzl, TE

English

PubMed

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Major hepatic resection and portal pressure

D-Scholarship@Pitt

I :! j. ,I I. 1.t MAJOR HEPATIC RESECTION AND PORTAL PRESSURE '{i' . ..... ~t Charles A. Bucrk, M.D., F.A.C.S., Charles W. Putnam, M.D., and -Thomas E. Starzl, M.D., F.A.C.S., Denver, Colorado DaK~ fj;' I' I~I-IN RECENT REPORTS in the surgical literature, an in-ci-ease in portal pressure following major resections of the liver has been described, and this elevated ~ressure has been related to an increased morbidity and mortality. However, in the University of Colorado series of'30 liver resections-including 17 tiisegmentectomies, five right lobectomies, five left lobectomies and three left lateral segmentectomies ~afl performed without mortality, no evidence of sPlanchnic sequestration was observed. To docu-ment this clin,ical experience, portal pressures were obtained both before and after resection on three cOnsecutive patients undergoing hepatic triseg-ni~ntectomy in whom 80 per cent or more of the liver was removed. ~K npoR TS OF PATIENTS mAqfb~q 1. This' 57 year old male had a large tumor of the liver found on routine physical ~amination three .. -eeks prior to admission. Angiography revealed a large tumor blush in the right lobe of the liver, and on 20 March 1975, he underwent hepatic trisegmentectomy. .',ftcr initial mobilization, portal pressure measured directly through a portal vein cannula was 180 milli-Bitcrs of saline solution. :;!lc then underwent an anatomic trisegmentectomy; the resected specimen weighed 1,200 grams. The esti-l!Iated blood loss was 1,500 milliliteu which was replaced wi!h 4 units of whole blood plus 2 liters of lactated imger's solution. At no time during the procedure was l!ehypotensive, and the central venous pressure remained mthc range of 17 to 21 centimeters of saline solution. During this six hour operation, there was never any evi-dence of splanchnic engorgement. Approximately 45 ~utes after the completion of the resection, the portal p!1:ssure measured 172 millimeters of saline solution. The PCIIStoperative course was uncomplicated, and he was di!charged on the 19th postoperative day. . PATIENT 2. This 40 year old female was considered for ~atic trisegmentectomy when she was found to have :II\-asive carcinoma of the gallbladder after cholecystec-llImy for cholelithiasis. A hepatic trisegmentectomy was j)l:r{ormed on 29 April 1975. The initial portal vein prcs-from the Department of Surgery, The University of Colorado ~lCal Center, and the Veterans Administration Hospital, Denver. .... work was supported by research Grant Nos. ~fofp 8118·01 tIC 7227-01 from the Veterans Administration, bv Grant Nos. !!:-17260 and AM-07772 from the National Instit';tes of Health ... _ by Grant Nos. RR-OOOSI and RR·OOO69 from the General a-:::al Re'earch Centers Program of the Division of Research _', tces, :'\ational Institut.,,; of Health. sure obtained· before extensive dissection was 200 milli-meters of saline solution. The entire procedure lasted ten hours, with an estimated blood loss of 3,500 milliliters. This was replaced with 7 units of whole blood. In addi-tion, the patient received 1,800 milliliters of crystalloid and 200 milliliters offresh frozen plasma. No hypotension was encountered during the procedure, and the central venous pressure remained relatively co'flstant. The re-sected specimen weighed 1,295 grams and contained a solitary metastasis deep within the parenchyma at the junction of the true rig\:lt and left lobes. Aftcr completion of the resection, the portal pressure measured 195 millimeters of saline solution. At no time during the procedure was splanchnic engorgement observed. She recovered uneventfully, but the disease has recurred one and one-half years after the operation was performed. ,-PATIENT 3. This 12 year old girl was referred from Germany with the diagnosis of sarcoma of the liver. Following a confirmatory work-up, an hepatic triseg-mentectomy was performed on 24 May 1975. Explora-tion revealed a bulky tumor was replacing most of the right lobe of the liver and was extending slightly to the left of the falciform ligament. Before any significant dis-section was performed, the portal vein was cannulated, and a pressure of 160 millimeters of saline solution was obtained. Because ofthe bulkiness of the tumor, dissection proved difficult, with an estimated blood loss of 3,500 milliliters and a total operating time of ten hours. The systolic blood pressure remained fairly constant at 110 millimeters of mercury until the time of hepatic transection when it fell to 70 millimeters of mercury. This fall was associated with brisk bleeding from the liver bed and responded rapidly to volume replacement. The central venous pressure, which had also remained constant throughout the procedure, likewise fell at this time but also re-sponded rapidly. Total fluid replacement was 3,500 milliliters of whole blood plus an additional 3 liters of crystalloid solution. The resected specimen weighed 1,760 grams and represented approximately 80 per cent of the liver of this patient. One hour following the completion of the resection, when blood volume had again normalized, the portal vein pressure measured 154 millimeters of saline solution. At no time was there clinical evidence of engorgement of the splanchnic bed. The postoperative course, although protracted because of persistent bile and fluid drainage from the wound, was benign, and she made an unevent-ful recovery. 853 ; ,--I~ -f~ :z: . ' ~ , -~ :') --.. < -854 Surgery, Gynfcology & Obstetrics· JUlie 1977· Volume 144 DISCUSSION Reports of splanchnic congestion following liga-tion of the portal vein and partial hepatectomy in animals have caused understandable concern among clinical investigators. The observation that splanchnic pooling occurred following occlusion of the portal vein was first made by Ore (7) in 1856. Thereafter, numerous other investigators, includ-ing Bernard (2) and Lautenbach (5), reported simi-lar results, and by the early 1900s, the hypothesis of splanchnic pooling, decreased venous return with a decrease in effective circulating volume, was accepted as the mechanism of death in these ani-mals. In dogs, rabbits and rats, occlusion of the main portal vein invariably caused death. Investigators assumed that incomplete interruption of portal venous flow by partial hepatectomy would also partially impede splanchnic venous return. \,yith the dog being lIsed as a model, Aronsen ,and col-leagues (1) reported a 33 per cent reduction in cardiac output and a 50 per cent reduction in stroke volume following a 50 per cent hepatec-tomy. In other studies, sustained portal hyperten-sion was reported following substantial liver resec-tions in dogs and rats. After reviewing hepatic resections in 38 humans, Stone (9) emphasized the importance of splanchnic bed pooling and advised transfusing volume that exceeded the calculated loss to prevent shock fol-lowing a 30 per cent hepatectomy. Stone (9) fur-ther suggested that splanchnic sequestration played a major role in the early deaths following major hepatic resection . The hypothesized physiologic mechanisms for splanchnic sequestration were the reduction of hepatic outflow caused by a reduction in the total number' of hepatic veins or a diminution in the hepatic mass available for egress of splanchnic flow. However, the ability of the liver to handle rather marked alterations of hepatic flow without changes in portal pressure is well known. Results of in vivo studies by-Bloch (3) have shown that only 60 per cent of sinusoids are functioning in the steady state. This would theoretically allow for some loss ofliver mass without alteration in portal pressure. That the normal liver can withstand even greater splanchnic flows was pointed out by Hopkinson and Schenk (4), who noted a 76 per cent increase in portal flow without evidence of increased portal preSSure fol_ lowing a test meal. In addition, it is dangerous to extrapolate from the dog to man with regard to splanchnic heme). dynamics. For example, although acute occlusinn of the portal vein is uniformly fatal in the dog, it :J not immediately fatal in monkeys, actordin~ t(, Milnes and Child (6), or in other species that haw true retroperitoneal portions of the gastrointestin"i tract and associated organs. Results of our previous experience (8) ha\r shown that, with careful anatomic dissection anc the absence of clinical disease in the nonresect~d liver remnant, major hepatic resections produce no clinical evidence of increased portal pressure Or splanchnic sequestration. SUMMARY Although other reports have stressed the inevitJ' bility of portal hypertension and splanchnic poolin~ following major liver resections, clinical observa. tions during 30 major hepatic resections and measurements of portal pressure in three consecu-tive trisegmentectomies fail to support this conten-tion. If the remaining liver is normal and careful . anatomic dissection is used, major resections can be performed without inducing portal hypertension. REFERENCES 1. ARONSON, K. F., ERICSON, B., GRUNDSELL, H., 3nd others. Disappearance rate of xenon 133 from the livro' following partial hepatectomy in dogs. Acta Chir. Seand., 1969, 135: SIt. 2. BERNARD, C. Lecons sur les propietes physiologique et 10 alterations pathologique des liquiches de l'organismc. Vol. II, p. 190. Paris: J. B. Balliere et Fils, 1859. 3. BLOCH, E. H. The termination of hepatic arteriol~ and the functional unit of the liver as determined by micro-scopy of the living organ. Ann. N. Y. Acad. SeL, 1970. 170: 78. 4. HOPKINSON, B. R., and SCHENK, \V. G. The electromag. netic measurement of liver blood flow and cardiac out-put in conscious dogs during feeding and exercises. Sur· gery, 1968, 63: 970. 5. LAUTENBACH, B. F. On a new function ohhe liver. Merl. Times & Reg., Phil., 1876, 7: 387. 6. MILNES, R. F., and CHILD, C. G. Acute occlusion bv ligature of the portal vein in macacus rhesus monkey. Proc. Soc. Exp. BioI. Med., 1949, 70: 332. 7. ORE. Influence de I'obliteration de la veine porte sur b secretion de la bile et sur la function glycogenique dll foie. Compt. rend. Acad. d Sc., Par., 1856, 43: 463. 8. STARZL, T. E., BELL, R. H., BE ART, R. W., and mu~AlfK C. \"1. Hepatic trisegmentectomy and other Ih'er r~D tions. Surg. Gynecol. Obstet., 1975, 141: 429. 9. STONE, H. H. Major hepatic resections in children. J. Pediatr. Surg., 1975, 10: 127. 

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Major hepatic resection and portal pressure

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