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Postoperative Management After Hepatic Resection Lindsay J Journal of Gastrointestinal Oncology, Vol 3, No 1, March 2012 41 Review Article Postoperative management after hepatic resection Lindsay J. Wrighton, Karen R. O’Bosky, Jukes P. Namm, Maheswari Senthil Department of Surgery, Loma Linda University, Loma Linda, California, USA ABSTRACT Hepatic resection has become the mainstay of treatment for both primary and certain secondary malignancies. Outcomes after hepatic resection have significantly improved with advances in surgical and anesthetic techniques and perioperative care. Metabolic and functional changes after hepatic resection are unique and cause significant challenges in manage- ment. In-depth understanding of hepatic physiology is essential to properly address the postoperative issues. Strategies implemented in the postoperative period to improve outcomes include adequate nutritional support, proper glycemic control, and interventions to reduce postoperative infectious complications among several others. This review article fo- cuses on the major postoperative issues after hepatic resection and presents the current management. KEY WORDS Management; postoperative; hepatic resection; liver resection J Gastrointest Oncol 2012;3:41-47. DOI: 10.3978/j.issn.2078-6891.2012.003 Introduction are further accentuated by derangements of liver function. Maintenance of adequate fluid balance and normal renal Outcomes after hepatic resection have significantly function is critical. Cirrhotics are prone to fluid shifts, improved over the last few decades (1-4). Although, no vasodilation and resultant hypotension. In this setting, single factor is solely responsible, overall advances in colloids rather than crystalloids should be administered surgical and anesthetic techniques, better understanding to restore intravascular volume. New onset postoperative of hepatic physiology and improvement in perioperative ascites frequently occurs in cirrhotic patients. Management management have all been contributory. Majority of with sodium restriction and judicious use of diuretic therapy postoperative management issues after liver resection is recommended. Paracentesis may be necessary to prevent are unique and require a thorough understanding of liver tense ascites. metabolism and the pathophysiology of liver disease. The Hyperlactemia and hypophosphatemia are common purpose of this review is to elaborate on specific early derangements in patients undergoing liver resection. postoperative management issues after liver resection, Gluconeogenesis carried out by the liver normally consumes examine current evidence and present the management 40-60% of lactate. When the liver is damaged or stressed, options. it produces lactate rather than metabolizing it. Watanabe, et al., examined the relationship between lactate and base Fluid and Electrolyte management excess with clinical outcomes in 151 hepatic resection patients. The initial arterial plasma lactate concentration The immediate postoperative period after hepatic resection was significantly higher in non-survivors than in survivors, is characterized by fluid and electrolyte imbalances that and correlated with bilirubin levels and was an excellent independent predictor of morbidity and mortality. Due No potential conflict of interest. to the additive effects of lactate-containing intravenous Corresponding to: Maheswari Senthil, MD. Department of Surgery, Division solution, non-lactate containing solutions are recommended of Surgical Oncology, Loma Linda University, Coleman Pavilion, Room # for postoperative use (5). 21112, 11175 Campus Street, Loma Linda, California, USA. Tel: 909-558-8390; Fax: 909-558-0236. Email: [email protected]. Hypophosphatemia Submitted Dec 01, 2011. Accepted for publication Jan 12, 2012. Available at www.thejgo.org Hypophosphatemia is encountered in nearly all patients ISSN:2078-6891 after major hepatic resection. The pathogenesis of © Pioneer Bioscience Publishing Company. All rights reserved. hypophosphatemia after hepatic resection is poorly 42 Wrighton et al. Postoperative management after hepatic resection understood and is generally believed to be due to increased nutritional status may not require any special intervention phosphate uptake by regenerating hepatocytes. However, and should be started on early oral/enteral diet. On the recent work by several investigators has suggested that other hand, patients who are either malnourished, with or excessive urinary losses mediated by phosphaturic without compromised liver function (cirrhosis or steatosis) mediators termed phosphatonins might be responsible for and who undergo major hepatic resection will benefit from post-hepatic resection hypophosphatemia (6,7). Whether perioperative nutritional support preferably through enteral this reflects an increased production of phosphaturic route. The benefit of early enteral nutrition has now been mediators by the injured liver versus decreased clearance of firmly established in a wide variety of surgical patients. a circulating mediator by the remnant liver is unclear. Richter, et al. (11) evaluated five randomized controlled Hypophosphatemia results in impaired energy studies that compared enteral versus parenteral nutrition metabolism, leading to cellular dysfunction in many organ in the post-hepatic resection patients (12-16). Based on the systems including respiratory failure, cardiac arrhythmias, results, the authors concluded that enteral nutrition resulted hematologic dysfunction, insulin resistance, and in significantly lower rate of wound infections and catheter neuromuscular dysfunction (8,9). Standard liver resection related complications than parenteral nutrition. While there management includes adequate replacement of phosphate was no difference in mortality, patients receiving enteral with supplementation of maintenance fluids with potassium nutrition showed better post-operative immune competence phosphate and oral/parenteral replacement. Currently, as evidenced by decreased post-operative infectious management of hypophosphatemia relies on serum complications. Hotta,et al. found that supplementation with phosphate measurements, which may not be an accurate TPN had no effect on the post-operative outcomes (17). measure of actual intracellular phosphate levels due to intra- Current evidence strongly supports the use of enteral route extracellular shifts. Acidosis can cause a shift of intracellular for nutritional support unless otherwise contraindicated. phosphate to extracellular space resulting in normalization In addition to early enteral nutrition, branched chain of extracellular phosphate levels. Alternatively, amino acids and other immune-enhancing agents have measurements of serum 2,3- diphosphoglycerol (DPG) received recent attention and deserve special mention. and nucleotide breakdown products in the urine have Liver disease results in altered amino acid metabolism been reported to be more sensitive physiologic markers characterized by low circulating levels of branched chain of hypophosphatemia-related cellular stress. Persistently amino acids (leucine, isoleucine and valine), elevated low serum 2,3-DPG levels and high nucleotide breakdown circulating levels of methionine and aromatic amino products in the urine would potentially indicate inadequate acids. Results from two large randomized controlled trials intracellular phosphate replenishment (7). Further have shown that branched chain amino acids (BCAA) validation studies are needed to assess the clinical utility of supplementation in patients with advanced cirrhosis was these measures in the management of hypophosphatemia. associated with improved nutritional status and decreased In summary, hypophosphatemia after hepatic resection can frequency of complications of cirrhosis (18,19). Okabayashi lead to deleterious consequences and should be properly et al. evaluated the impact of oral supplementation of addressed. Universally accepted method for investigation, branched chain amino acids and carbohydrates on quality optimal replacement and target serum levels are lacking. of life (QOL) measures in patients undergoing hepatic Future studies that further elucidate the pathophysiology resection (20). In this study QOL measures was assessed of hypophosphatemia after hepatic resection might lead to by subjective perception of functioning and physical, better management. mental, and social well-being and were evaluated before and after surgery, up to 12 months post-operatively. The Nutrition BCAA group showed steadily improving QOL measures from pre-operative measurements - this trend continued 12 The post-hepatic resection period is characterized by months post-operatively even after supplements had been a catabolic state, often with glucose and electrolyte discontinued, while the control group showed no change. imbalances as the body attempts to supply the high demand The authors concluded that nutritional supplementation of the regenerating liver (10). Nutritional support during with BCAA restored nutritional status and “whole-body this critical period is of paramount importance to ensure kinetics” in patients following hepatic resection, with adequate hepatic regeneration and postoperative-recovery. subjective improvement in post-operative quality of life. A perioperative nutritional plan should be devised for each In animal studies, BCAA supplementation has been individual patient based on the nutritional status and hepatic shown to promote liver regeneration after major hepatic function. Non-cirrhotic patients with adequate preoperative resection
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