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Intervention Review

Cardiopulmonary interventions to decrease blood loss and blood transfusion requirements for liver resection

  1. Kurinchi Selvan Gurusamy*,
  2. Jun Li,
  3. Dinesh Sharma,
  4. Brian R Davidson

Editorial Group: Cochrane Hepato-Biliary Group

Published Online: 7 OCT 2009

Assessed as up-to-date: 7 NOV 2008

DOI: 10.1002/14651858.CD007338.pub2


How to Cite

Gurusamy KS, Li J, Sharma D, Davidson BR. Cardiopulmonary interventions to decrease blood loss and blood transfusion requirements for liver resection. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD007338. DOI: 10.1002/14651858.CD007338.pub2.

Author Information

  1. Royal Free Hospital and University College School of Medicine, University Department of Surgery, London, UK

*Kurinchi Selvan Gurusamy, University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, NW3 2QG, UK. kurinchi2k@hotmail.com.

Publication History

  1. Publication Status: New
  2. Published Online: 7 OCT 2009

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Blood loss during liver resection is one of the most important factors affecting the peri-operative outcomes of patients undergoing liver resection.

Objectives

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.

Search 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 November 2008 for identifying the randomised trials.

Selection criteria

We included all randomised clinical trials comparing various cardiopulmonary interventions aimed at decreasing blood loss and allogeneic blood transfusion requirements in liver resection. Trials were included irrespective of whether they included major or minor liver resections, normal or cirrhotic livers, vascular occlusion was used or not, and irrespective of the reason for liver resection.

Data collection and analysis

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.

Main results

Nine trials involving 587 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 or other peri-operative morbidity. None of the trials reported long-term survival or liver failure.The risk ratio of requiring allogeneic blood transfusion was significantly lower in the haemodilution and haemodilution with controlled hypotension groups than the respective control groups. Other interventions did not show significant decreases of allogeneic transfusion requirements.

Authors' conclusions

None of the interventions seem 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. Further randomised clinical trials with low risk of bias and random errors assessing 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 liver resections. Trials need to be designed to assess the effect of a combination of different interventions in liver resections.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Haemodilution may show promise in decreasing blood loss and blood transfusion requirements

Blood loss during liver resection (partial removal of liver) is one of the important factors affecting the post-operative complications of patients. Allogeneic blood transfusion (using blood donated by a different individual) is associated with increased morbidity and lower survival in patients with liver cancer. This systematic review was aimed at determining whether any cardiopulmonary (interventions that change the circulation or breathing during surgery) intervention decreased blood loss or decreased allogeneic blood transfusion requirements in patients undergoing liver resections. This review included nine trials with 587 patients. All trials had high risk of bias ('systematic error') as well of play of chance ('random error'). The interventions included low central venous pressure (CVP; pressure in the major neck veins), autologous blood donation (using the patient's own blood obtained prior to liver resection), haemodilution (replacing blood with other fluids), haemodilution with controlled hypotension (lowering the blood pressure in addition to diluting the blood), and hypoventilation (decrease the rate of artificial breathing), and were compared with controls not receiving the interventions. There was no difference in the death or complications due to surgery in any of the comparisons. Long-term survival was not reported in any of the trials. Fewer patients required transfusion of blood donated by others when haemodilution or haemodilution with controlled hypotension were compared to controls. The other comparisons did not decrease the transfusion requirements. However, there is a high risk of type I errors (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 and the small sample size in each trial as well as the inherent risk of bias (systematic errors). Haemodilution shows promise in the reduction of blood transfusion requirements in liver resections. Further randomised clinical trials with low risk of bias (systematic errors) and low risk of play of chance (random errors) which assess clinically important outcomes (such as death and complications due to operation) are necessary to assess any cardiopulmonary interventions aimed at decreasing blood loss in liver resections. Trials need to be designed to assess the effect of a combination of different interventions in liver resections.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

採用心肺干預以減少肝臟切除術之失血和輸血需求

肝臟切除過程中的失血是影響接受肝臟切除術的病人手術結果的重要因素之一。

目標

確定採用心肺干預以減少接受肝臟切除術後病人的同種異體輸血需求的利弊。

搜尋策略

我們搜尋截至2008年9月的The Cochrane HepatoBiliary Group Controlled Trials Register, The Cochrane Library的Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE和Science Citation Index Expanded, 以找出隨機試驗。

選擇標準

我們挑選所有比較各種心肺干預方法的隨機臨床試驗,這些方法的目的是減少肝臟切除術的失血和輸血需求。這些臨床試驗並沒有限制大小、正常或是硬化肝臟、是否採用血流阻斷以及切除原因。

資料收集與分析

2位作者獨立確定需收錄的試驗以及摘錄數據。我們採用RevMan 以固定效果模式和隨機效果模式分析資料。根據治療意向分析或已獲取的個案分析,我們對每次結果計算風險比率 (risk ratio ,RR), 平均差(mean difference,MD), 標準平均差 (standardised mean difference,SMD) 及其95% CI。針對只有一個試驗所產生的二分法結果,我們對此結果執行薛費氏精確檢定。

主要結論

共有9個試驗符合收錄標準,587 位病人參與。 干預療法包括低中心靜脈壓(central venous pressure ,CVP)、自體輸血、血液稀釋,血液稀釋合併控制低血壓以及通氣。多數比較只包括1個或2個試驗。所有試驗具有較高的偏誤風險。在手術期間的死亡率或其他手術期的發病率沒有顯著差異。並沒有試驗報告有長期存活率或肝臟衰竭。在血液稀釋組,血液稀釋聯合控制低血壓同種異體輸血組的風險比率明顯低於各自的控制組。其他干預法沒有並不會明顯降低同種異體輸血要求。

作者結論

似乎沒有一項干預法能夠減低手術期間的發病率或對長期存活率有益]。血液稀釋顯示能夠降低肝臟切除手術中的輸血要求。但是, 由於只包括了少數試驗,每次試驗的樣本小,偏誤風險高,所以很可能產生第一類誤差(錯誤總結一種干預法有益,但是實際上並沒有益處)和第二類誤差(錯誤總結一種干預法沒有益處,但是實際上有益)。針對利用不同之干預法以降低肝臟切除之失血及輸血量,更多評估臨床重要結果(如手術期間死已率),且有較低偏誤風險及隨機誤差的試驗是必要的。試驗需要設計成能夠評估當合併多種干預法對肝臟切除術的影響。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

血液稀釋可能可以減少肝臟切除術的血液損失和輸血要求。 肝臟切除期間失血(移除部分肝臟)是影響病人術後併發症的重要因素之一。肝癌病人接受同種異體輸血(使用另外一個人捐的血液)已確定和發病率增加以及降低存活率有關。本次系統性回顧目的是確定是否心肺干預療法(在手術過程中,改變血液迴圈或呼吸的干預療法)能夠減少接受肝臟切除術病人的血液損失或減少同種異體輸血要求。本次回顧包括9個試驗,共有587 位病人。所有試驗具有較高的偏見風險(‘系統性誤差’)和機率風險 (‘隨機誤差’)。干預療法包括低中心靜脈壓(CVP;主要頸部靜脈的壓力,自體捐血(使用病人自己在肝切除之前採集到的血), 血液稀釋(把血液替換成其他液體),血液稀釋聯合控制低血壓(降低血壓還有稀釋血液)和低通氣(減少人工呼吸的次數),上述干預療法分別和無干預療法的控制組進行比較。任何一組比較在死亡率或手術引起的併發症方面沒有明顯差異。沒有試驗報導長期存活率。和控制組相比,血液稀釋組或血液稀釋聯合控制低血壓組的需要輸血的人數較少。 其他比較沒有減少輸血需求。但是, 由於只包括了少數試驗,每次試驗的樣本小,偏誤風險高(系統性誤差).,所以第一類誤差(錯誤總結一種干預法有益,但實際上並沒有益處)和第二類誤差(錯誤總結一種干預法沒有益處,但是實際上有益)的風險較高。血液稀釋顯示能夠減少肝臟切除術的血液損失和輸血需求。需要更多偏誤風險低(系統性誤差)且隨機機率低(隨機誤差)的隨機臨床試驗,用來評估臨床重要的結果(例如,因手術引起的死亡和併發症),以此評估任意一種以減少肝臟切除術的血液損失為目標的心肺干預療法。試驗需要設計成能夠評估合併多種干預法對肝臟切除術的影響。