title: Cardiopulmonary interventions to decrease blood loss and blood transfusion requirements for liver resection.
abstract: BACKGROUND
  Blood loss during liver resection is one of the most important factors affecting the peri-operative outcomes of patients undergoing liver resection.
  
  
  OBJECTIVE
  To determine the benefits and harms of cardiopulmonary interventions to decrease blood loss and to decrease allogeneic blood transfusion requirements in patients undergoing liver resections.
  
  
  METHODS
  We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until November 2008 for identifying the randomised trials.
  
  
  METHODS
  We included all randomised clinical trials comparing various cardiopulmonary interventions aimed at decreasing blood loss and allogeneic blood transfusion requirements in liver resection. Trials were included irrespective of whether they included major or minor liver resections, normal or cirrhotic livers, vascular occlusion was used or not, and irrespective of the reason for liver resection.
  
  
  METHODS
  Two authors independently identified trials for inclusion and independently extracted data. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis or available case-analysis. For dichotomous outcomes with only one trial included under the outcome, we performed the Fisher's exact test.
  
  
  RESULTS
  Nine trials involving 587 patients satisfied the inclusion criteria. The interventions included low central venous pressure (CVP), autologous blood donation, haemodilution, haemodilution with controlled hypotension, and hypoventilation. Only one or two trials were included under most comparisons. All trials had a high risk of bias. There was no significant difference in the peri-operative mortality or other peri-operative morbidity. None of the trials reported long-term survival or liver failure.The risk ratio of requiring allogeneic blood transfusion was significantly lower in the haemodilution and haemodilution with controlled hypotension groups than the respective control groups. Other interventions did not show significant decreases of allogeneic transfusion requirements.
  
  
  CONCLUSIONS
  None of the interventions seem to decrease peri-operative morbidity or offer any long-term survival benefit. Haemodilution shows promise in the reduction of blood transfusion requirements in liver resection surgery. However, there is a high risk of type I (erroneously concluding that an intervention is beneficial when it is actually not beneficial) and type II errors (erroneously concluding that an intervention is not beneficial when it is actually beneficial) because of the few trials included, the small sample size in each trial, and the high risk of bias. Further randomised clinical trials with low risk of bias and random errors assessing clinically important outcomes such as peri-operative mortality are necessary to assess any cardiopulmonary interventions aimed at decreasing blood loss and blood transfusion requirements in liver resections. Trials need to be designed to assess the effect of a combination of different interventions in liver resections.
authors.affiliation: University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
authors.forename: Kurinchi Selvan
authors.initials: KS
authors.lastname: Gurusamy
authors.forename: Jun
authors.initials: J
authors.lastname: Li
authors.forename: Dinesh
authors.initials: D
authors.lastname: Sharma
authors.forename: Brian R
authors.initials: BR
authors.lastname: Davidson
mesh_terms: D015982:Bias; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D001804:Blood Transfusion, Autologous / Q000379:methods; D002496:Central Venous Pressure / Q000502:physiology; D006438:Hemodilution / Q000379:methods; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D007023:Hypotension, Controlled; D016032:Randomized Controlled Trials as Topic; D012119:Respiration