title: Cardiopulmonary interventions to decrease blood loss and blood transfusion requirements for liver resection.
abstract: BACKGROUND
  Blood loss during liver resection is considered 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 January 2012 to identify randomised trials.
  
  
  METHODS
  We included all randomised clinical trials comparing various cardiopulmonary interventions aimed at decreasing blood loss and allogeneic blood transfusion requirements in patients undergoing liver resection. Trials were included irrespective of whether they included major or minor liver resections of 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
  Ten trials involving 617 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 in any of the comparisons: low CVP versus no intervention (3 trials, 0/88 (0%) patients in the low CVP group versus 1/89 (1.1%) patients in the no intervention group); autologous blood donation versus no intervention (1 trial, 0/40 (0%) versus 0/39 (0%)); haemodilution versus no intervention (2 trials, 1/73 (1.4%) versus 3/77 (3.9%) in one of these trials); haemodilution with controlled hypotension versus no intervention (1 trial, 0/10 (0%) versus 0/10 (0%)); haemodilution with bovine haemoglobin (HBOC-201) versus haemodilution with hydroxy ethyl starch (HES) (1 trial, 1/6 (16.7%) versus 0/6 (0%)); hypoventilation versus no intervention (1 trial, 0/40 (0%) versus 0/39 (0%)). None of the trials reported long-term survival or quality of life. The risk ratio of requiring allogeneic blood transfusion was significantly lower in the haemodilution versus no intervention groups (3 trials, 16/115 (weighted proportion = 14.2%) versus 41/118 (34.7%), RR 0.41 (95% CI 0.25 to 0.66), P = 0.0003); and for haemodilution with controlled hypotension versus no intervention (1 trial, 0/10 (0%) versus 10/10 (100%), P < 0.0001). There were no significant differences in the allogeneic transfusion requirements in the other comparisons which reported this outcome, such as low CVP versus no intervention, autologous blood donation versus control, and hypoventilation versus no intervention.
  
  
  CONCLUSIONS
  None of the interventions seemed 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 in the trials. Further randomised clinical trials with low risk of bias and random errors that assess 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 patients undergoing liver resections. Trials need to be designed to assess the effect of a combination of different interventions in liver resections.
authors.affiliation: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK. kurinchi2k@hotmail.com.
authors.forename: Kurinchi Selvan
authors.initials: KS
authors.lastname: Gurusamy
authors.forename: Jun
authors.initials: J
authors.lastname: Li
authors.forename: Jessica
authors.initials: J
authors.lastname: Vaughan
authors.forename: Dinesh
authors.initials: D
authors.lastname: Sharma
authors.forename: Brian R
authors.initials: BR
authors.lastname: Davidson
mesh_terms: 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