A 60-year-old woman has a right hemi-hepatectomy for invasive cholangio-carcinoma. She has been admitted to your unit for postoperative care
a) Describe in detail what problems she may develop in the first 48 hours and how you would treat them?
The perioperative complications could be classified into (1) that of any major upper abdominal surgery and (2) specifically that of a hemi-hepatectomy for cholangiocarcinoma; or divided into various systems, ie.
(1) Respiratory: Inadequate or excessive analgesia, pulmonary oedema from fluid overload, R. haemothorax, R. pneumothorax, R diaphragmatic dysfunction, V/Q mismatch from hepatic failure, aspiration and possibly early pulmonary infection or thromboembolism. Very rarely, intraoperative air embolism ®ARDS.
(2) Cardiovascular: Hypotension from bleeding, epidural block, perioperative myocardial ischaemia / infarction, Arrhythmias associated with electrolyte abnormalities.
(3) Gastro-intestinal failure: Prolonged ileus, pseudo-obstruction, ascites, G I haemorrhage. (4) Renal: Hepatorenal syndrome, acute tubular necrosis, oliguria.
(5) Hepatic: Cholangitis, hepatic failure, encephalopathy, coagulopathy, (6) CNS: Encephalopathy.
(7) Metabolic: hyperlactataemia, iNa+, lK+, hypoglycaemia.
(8) Premorbid condition: Possible ulcerative colitis/primary sclerosing cholangitis: Therefore, medication issues ie steroids, immune state, nutritional status etc.
Treatment is basically meticulous perioperative care with special regard to fluid and electrolyte balance, analgesia, coagulation control, and specific and supportive therapy for any individual complications that develop ie encephalopathy, hepatorenal syndrome etc.
This question closely resembles Question 1 from the second paper of 2006. In the interest of simplified revision, the answer to that question is reproduced below:
| Problems | Solutions |
| Airway issues | Extubate them in ICU (no difference in duration of ICU stay, regardless of where they are extubated) (Neelakanta et al, 1997). |
| Atelectasis | Use NIV (reintubation rates will be improved- Narita et al, 2010) |
| Bleeding | Use a low CVP strategy (2-5mmHg) Intraoperatively, insist on occlusive manoeuvres (eg. Pringle manoeuvre) |
| Analgesia | Remember the impaired clearance. Avoid benzodiazepines and long-acting opiates. Epidural seems to increase fluid requirements: use PCA instead. |
| Delirium | Hepatic encephalopathy may develop if the patient had abnormal liver function preoperatively. One is referred to the chapter on hepatic encephalopathy for details of its management (spoiler: a lot of lactulose is involved) |
| High lactate | Expect it. Unlikely to be related to real shock (more a reflection of poor residual liver function) Observe it. |
| Low phosphate | Expect it. Replace it. The phosphate is being absorbed by the regenerating liver. |
| Renal failure | In advanced cirrhosis, may represent hepatorenal syndrome. In other situations, it may be pre-renal (i.e. due to inadequate fluid resuscitation) or due to intraoperative renal vascular or ureteric injury. |
| Fluid overload | Use concentrated colloids to maintain intravascular volume (eg. 20% albumin). |
| Hypercatabolic state | Early enteral nutrition (not much benefit from TPN - Hotta et al, 2002) Optimal pre-operative nutrition is important. Branched-chain amino acids (BCAAs) should be mentioned, in spite of the fact that tey are probably pointless in this setting. |
| Hypoglycaemia | Attentive BSL monitoring |
| Coagulopathy | Attentive coag monitoring; likely no need for correction unless there is active bleeding |
| Infection | Mainly in the setting of bile leaks, abdominal collections, VAP or line-related sepsis. In any case, broad-spectrum cover will be deployed, some combination of an extended-spectrum β-lactam and lactamase inhibitor, eg. Tazocin. |
Jarnagin, William R., et al. "Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade." Annals of surgery 236.4 (2002): 397-407.
Page, Andrew J., and David A. Kooby. "Perioperative management of hepatic resection." Journal of gastrointestinal oncology 3.1 (2012): 19-27.
Wrighton, Lindsay J., et al. "Postoperative management after hepatic resection." Journal of gastrointestinal oncology 3.1 (2012): 41-47.
Thorat, Ashok, and Wei-Chen Lee. Critical Care Issues After Major Hepatic Surgery. INTECH Open Access Publisher, 2013.
Pagano, Duilio, et al. "The unreliability of continuous postoperative lactate monitoring after extended hepatectomies: single center experience." Updates in surgery 67.1 (2015): 33-37.
Ciuni, Roberto, et al. "Nutritional aspects in patient undergoing liver resection." Updates in surgery 63.4 (2011): 249-252.
Hotta, Tsukasa, et al. "Evaluation of postoperative nutritional state after hepatectomy for hepatocellular carcinoma." Hepato-gastroenterology 50.53 (2002): 1511-1516.
Richter, B., et al. "Nutritional support after open liver resection: a systematic review." Digestive surgery 23.3 (2006): 139-145.
Marchesini, Giulio, et al. "Nutritional supplementation with branched-chain amino acids in advanced cirrhosis: a double-blind, randomized trial." Gastroenterology 124.7 (2003): 1792-1801.
Kim, Say-June, Dong-Goo Kim, and Myung Duk Lee. "Effects of branched-chain amino acid infusions on liver regeneration and plasma amino acid patterns in partially hepatectomized rats." Hepato-gastroenterology 58.109 (2010): 1280-1285.
Neelakanta, Gundappa, et al. "Early tracheal extubation after liver transplantation." Journal of cardiothoracic and vascular anesthesia 11.2 (1997): 165-167.
Narita, Masato, et al. "Noninvasive ventilation improves the outcome of pulmonary complications after liver resection." Internal Medicine 49.15 (2010): 1501-1507.