title: In Situ Hypothermic Perfusion of the Liver for Complex Hepatic Resection: Surgical Refinements.
abstract: BACKGROUND
  While total vascular exclusion (TVE) with veno-venous bypass and hypothermia may be undertaken to increase liver tolerance for complex liver resection, these procedures are still associated with elevated rates of postoperative complications and mortality. In particular, one of the main issues of this strategy is the management of bleeding after declamping, which is enhanced by both hypothermic state and acidosis. To overcome this high risk of morbidity, several technical refinements might be undertaken and here described (with video).
  
  
  METHODS
  All patients, requiring TVE >60 min and liver cooling during hepatectomy, were retrospectively included in this study. Technical key points as (a) patient selection, (b) anesthetic management, (c) two-surgeon's technique, (d) preparation for clamping, (e) veno-venous bypass, (f) cooling of the liver, and (g) parenchymal transection, rewarming, and declamping are described and detailed.
  
  
  RESULTS
  From 2011 to 2013, we included 8 cases of liver resection with TVE, veno-venous bypass, and hypothermia for malignant disease. Due to the technical refinements, median observed overall blood loss of 550 ml (300-900) including 200 ml (50-300) at declamping and transfusion of packed red blood cell (PRBC) units was required in 5 patients with a mean of 1.25 PRBC/patient.
  
  
  CONCLUSIONS
  The association of TVE, veno-venous bypass, and liver cooling can reduce the time of transection, and blue dye injection and liver rewarming before declamping can reduce blood loss and coagulopathy. Altogether, limited blood loss can be achieved for these complex procedures and may allow to decreasing morbidity.
authors.affiliation: Department of Hepato-Pancreatic-Biliary Surgery, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Clichy, France.
authors.forename: François
authors.initials: F
authors.lastname: Cauchy
authors.affiliation: Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France. raffaele.brustia@gmail.com.
authors.forename: Raffaele
authors.initials: R
authors.lastname: Brustia
authors.affiliation: Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France.
authors.forename: Fabiano
authors.initials: F
authors.lastname: Perdigao
authors.affiliation: Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France.
authors.forename: Denis
authors.initials: D
authors.lastname: Bernard
authors.affiliation: Department of Hepato-Pancreatic-Biliary Surgery, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Clichy, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Soubrane
authors.affiliation: Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Scatton
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D001803:Blood Transfusion; D003250:Constriction; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D007036:Hypothermia, Induced; D008099:Liver / Q000601:surgery; D008113:Liver Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies
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