title: A Cochrane systematic review and network meta-analysis comparing treatment strategies aiming to decrease blood loss during liver resection.
abstract: BACKGROUND
  Intraoperative haemorrhage remains one of the major risks during liver resection, and perioperative blood loss and blood transfusion are important factors affecting perioperative morbidity and mortality. The aim of this study is to compare treatment strategies aiming to decrease blood loss during hepatectomy.
  
  
  METHODS
  A systematic review of the literature was performed to identify randomised controlled trials reporting on the method of vascular occlusion, parenchymal transection, and management of the cut surface during liver resection. A Bayesian network meta-analysis was performed using WinBUGS.
  
  
  RESULTS
  Seven trials reporting on 496 participants randomised to seven treatment strategies were analysed. Continuous vascular occlusion resulted in lower blood loss compared to no vascular occlusion when parenchymal transection was performed with clamp-crush and no fibrin sealant was used for the cut surface. People undergoing liver resection by continuous vascular occlusion had decreased amounts of blood transfused than people with intermittent vascular occlusion when parenchymal transection was performed with clamp-crush and no fibrin sealant. There was no significant difference in proportion of people transfused, mortality, or hospital stay between the different strategies. There were significantly more serious adverse events when surgery was performed using radiofrequency dissecting sealer compared with standard clamp-crush method in the absence of vascular occlusion and fibrin sealant.
  
  
  CONCLUSIONS
  Continuous vascular occlusion during hepatectomy results in decreased blood loss and decreased blood transfusion requirements. Further studies are needed to compare treatment strategies aiming to decrease blood loss, defined by their method of vascular occlusion, parenchymal transection, and management of the cut surface.
authors.affiliation: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK. Electronic address: csimillis@gmail.com.
authors.forename: Constantinos
authors.initials: C
authors.lastname: Simillis
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Tianjing
authors.initials: T
authors.lastname: Li
authors.affiliation: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK.
authors.forename: Jessica
authors.initials: J
authors.lastname: Vaughan
authors.affiliation: Department of Family Medicine, SUNY Upstate Medical University, Syracuse, NY, USA.
authors.forename: Lorne A
authors.initials: LA
authors.lastname: Becker
authors.affiliation: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK.
authors.forename: Brian R
authors.initials: BR
authors.lastname: Davidson
authors.affiliation: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK.
authors.forename: Kurinchi S
authors.initials: KS
authors.lastname: Gurusamy
mesh_terms: D001499:Bayes Theorem; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D001803:Blood Transfusion; D015718:Fibrin Tissue Adhesive; D006490:Hemostatics; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D008099:Liver / Q000098:blood supply; D016032:Randomized Controlled Trials as Topic
chemical_list: D015718:Fibrin Tissue Adhesive; D006490:Hemostatics
keywords: Blood loss; Fibrin sealant; Hepatectomy; Liver transection; Morbidity; Vascular occlusion