0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Transfusion Criteria for Fresh Frozen Plasma in Liver Resection A 3 + 3 Cohort Expansion Study FREE

Shintaro Yamazaki, MD; Tadatoshi Takayama, MD; Yuki Kimura, MD; Masamichi Moriguchi, MD; Tokio Higaki, MD; Hisashi Nakayama, MD; Masashi Fujii, MD; Masatoshi Makuuchi, MD
[+] Author Affiliations

Author Affiliations: Department of Digestive Surgery, Nihon University School of Medicine (Drs Yamazaki, Takayama, Kimura, Moriguchi, Higaki, Nakayama, and Fujii), and Department of Hepato-Biliary-Pancreatic Surgery, Japanese Red Cross Medical Center (Dr Makuuchi), Tokyo, Japan.


Arch Surg. 2011;146(11):1293-1299. doi:10.1001/archsurg.2011.293.
Text Size: A A A
Published online

Objective To establish transfusion criteria for use of fresh frozen plasma (FFP) in liver resection.

Background Fresh frozen plasma has been transfused in liver resection without adequate supporting evidence, leading to unnecessary use.

Design Prospective study using a phase 1 dose-escalation, 3 + 3 cohort expansion design, modified for FFP transfusion. We designated a serum albumin level of 3.0 g/dL (step 1) as the starting limit for no transfusion and reduced the level in 0.2-g/dL steps. Advancement to the next step was permitted when the albumin level equaled the target value for the previous step in 3 patients. If the albumin value on postoperative day 2 fell below the target value, 100 mL of albumin, 25%, was transfused on that day and on postoperative day 3. The study continued until high-grade postoperative complications occurred without transfusion. If 1 of 3 patients developed Clavien-Dindo grade II or higher complications, 3 more patients (3 + 3 cohort) were added to the same step.

Setting Hepatobiliary pancreatic surgery center of a university hospital.

Patients Patients with hepatocellular carcinoma who had had Child-Pugh class A liver function and an intraoperative blood loss of less than 1000 mL.

Intervention Transfusion or no transfusion of FFP.

Main Outcome Measure Reduction of transfusion rate in liver resection.

Results Of the 213 consecutive patients with liver cancer enrolled, 172 patients (80.8%) fulfilled the inclusion criteria. Step progression proceeded until step 5 (albumin level, 2.2 g/dL) without high-grade complications, but step 2 (albumin level, 2.8 g/dL) required 63 patients to complete because 1 patient developed grade II complications (massive ascites). Step progression was broken off at step 5 in the 172nd patient because the postoperative day 2 albumin value did not fall below the step 4 level (2.4 g/dL), defined as the goal limit. The overall operative morbidity rate was 27.9%; the mortality rate was 0%. The FFP transfusion rate was significantly reduced from 48.6% in a previous series involving 222 patients (unpublished historical data from our institution) to 0.6% (1 of 172 patients) in the present study (P < .001). The postoperative hospital stay in the present study was significantly shorter than that in our previous series (13 vs 16 days; P = .01). Total medical costs were significantly reduced from a median of $21 061 (range, 10 032-59 410) to $17 267 (11 823-35 785; P = .04).

Conclusion In liver resection, FFP transfusion is not necessary in patients with serum albumin levels higher than 2.4 g/dL on postoperative day 2.

Figures in this Article

In high-volume medical centers, liver resection for malignant neoplasms has been performed with acceptable blood loss (median, 607 mL; range, 509-750 mL) and satisfactory operative morbidity (25%; range, 16%-44%) and mortality (1.3%; range, 0%-4.7%).17 Minimizing intraoperative blood loss, avoiding blood transfusion, and strict postoperative management have contributed to these excellent outcomes.811

Fresh frozen plasma (FFP) has been transfused for supplementation of coagulation factors and maintenance of colloid osmotic balance by supplementation of albumin.3,12 Perioperative management with the use of FFP transfusion has contributed to decreased morbidity and mortality. No deaths were reported in a recent series.3

However, FFP transfusion is now considered only in specific circumstances, and most high-volume medical centers use very limited amounts, with no apparent effect on outcomes.13,14 The indication for FFP transfusion and the reduction in the volume are attributed to the use of hospital-specific criteria developed empirically; an accurate categorization of patients with no need for perioperative FFP transfusion is unavailable.14 All currently available criteria have been defined retrospectively and generally include an international normalized ratio (INR) less than 1.501518 or maintaining postoperative serum albumin levels higher than 3.0 g/dL (to convert to grams per liter, multiply by 10).3,12

To accurately categorize patients with no need for perioperative FFP transfusion, we performed a prospective study in patients who underwent elective liver resection for cancer. Based on our perioperative management, we used the postoperative serum albumin level as the most straightforward indicator of the need for FFP transfusion3,19,20 and then examined how far the level could be decreased without causing adverse events. Our study protocol was derived from a prospective dose-escalation design (ie, a 3 + 3 cohort expansion design),21 often used to set maximum dosage limits in phase 1 trials of anticancer drugs.

INCLUSION CRITERIA

The eligibility criteria included liver function defined as Child-Pugh class A, curative hepatic resection for malignant neoplasms, an intraoperative blood loss of less than 1000 mL without blood or FFP transfusions, adequate bone marrow and renal reserves (white blood cells, >3000/μL [to convert to 109 per liter, multiply by 0.001]; platelets, >50 × 103/μL [to convert to 109 per liter, multiply by 1.0]; and serum creatinine, <1.5 mg/dL [to convert to micromoles per liter, multiply by 88.4]), and age between 15 and 80 years. Exclusion criteria were preoperative serum albumin levels less than 3.0 g/dL and postoperative occurrence of unstable cardiovascular or renal function, or other serious medical conditions that could not be treated effectively without albumin administration.

An English-language summary of the protocol is available at the Clinical Trials Registry managed by the University Hospital Medical Information Network in Japan (http://www.umin.ac.jp/ctr/index.htm: UMIN000002898). This study was approved by the Nihon University Itabashi Hospital ethics committee, and written informed consent was obtained from all patients.

STEP PROGRESSION PROFILE

This prospective study was based on the 3 + 3 cohort expansion design.21 The concept of the dose-escalation model is to reach the safety limit in the fewest number of patients. In the present study, the starting target value for the serum albumin level on postoperative day (POD) 2 was 3.0 g/dL (step 1), which was defined according to our FFP transfusion criteria3,12,22 (Figure 1). The target level was decreased in 0.2-g/dL steps thereafter (eg, 2.8 g/dL for step 2 and 2.6 g/dL for step 3). When the serum albumin level on POD2 equaled the target step value in 3 patients, the next step was begun. If the serum albumin value on POD2 was below the target step value, the patient was given 100 mL of albumin, 25% (Buminate; Baxter Healthcare Corporation, Westlake Village, California), on POD2 and POD3. No further transfusions were given unless complications occurred.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Step progression profile. To convert albumin to grams per liter, multiply by 10.

Progression to the next step was allowed until postoperative complications developed without transfusion or the serum albumin level reached the lowest limit. The complication grade was defined according to the Clavien-Dindo classification, which includes therapeutic consequences and severity of complications.23 For each complication, the severity was defined on a scale of I to V. The need for blood transfusion was categorized as grade II. If 1 of 3 patients developed grade II complications, 3 more patients were added to the same step. If grade II or III complications occurred a second time during the same step or grade IV or V complications developed, step advancement was terminated. The lowest limit was defined as the step in which no patient reached the target value. The step progression was discontinued when the serum albumin level did not reach the target step value in any patient after the same number of patients as that in the previous step had been enrolled. The POD2 serum INR and serum albumin values in the step progression protocol were recorded to compare the trends of these variables. Postoperative complications were assessed by a single liver surgeon (Y.K.) who was not involved in subsequent surgical procedures or postoperative treatments.

LIVER RESECTION

The indications for surgical resection and the operative procedures were in accordance with the criteria of Makuuchi et al.24 Anatomic resection of the Couinaud segment was the first-line operative procedure if permitted by the patient's functional liver reserve. Minor hepatectomy was defined as limited resection or resection of up to 2 Couinaud segments, and major hepatectomy consisted of more than 2 segmentectomies, left or right hepatectomy, or extended hemihepatectomy.25 Hepatic parenchymal transection was guided ultrasonographically and performed by the clamp-crushing method with the inflow blood-occlusion technique.25 A closed irrigation drain was placed in each cut surface of the liver.

Total surgical costs per patient were compared between the present study and our previous series, on the basis of the Japanese National Health Insurance system. The costs included all hospital fees (eg, operation, drugs, and nursing care) but excluded physicians' fees.

STATISTICAL ANALYSIS

The χ2 test, paired t test, and Mann-Whitney test were used to compare nominal and continuous variables. Multiple comparisons of trends in laboratory indices of liver function were made by 1-way repeated-measures analysis of variance. Significance was defined as P ≤ .05. All analyses were performed using a statistical software package (JMP version 8.0; SAS Institute, Inc, Cary, North Carolina).

RISK ANALYSIS OF THE COMPLICATIONS

Risk factors for postoperative complications were analyzed among 11 perioperative variables in our previous series of patients (2002-2006; 222 patients) who met the same eligibility criteria as those in the present study (Table 1). Among 3 independent factors, we used only the POD2 albumin value (odds ratio, 2.91; 95% CI, 1.58-92.1; P = .02) as an indicator of the need for postoperative intervention.

Table Graphic Jump LocationTable 1. Analysis of Postoperative Complications in 222 Patients (2002-2006)a
ELIGIBILITY CRITERIA

Between January 1, 2007, and June 30, 2008, we enrolled 213 consecutive patients with liver cancer who were scheduled to undergo liver resection (Figure 1). Forty-one patients were excluded; the remaining 172 patients (80.8%) were included. No patient who met the eligibility criteria received intraoperative FFP transfusion.

STEP PROGRESSION PROFILE

The step progression proceeded from step 1 to step 5 (Figure 1). Step 1 required 15 patients: the serum albumin level on POD2 equaled the target value of 3.0 g/dL in the 5th, 12th, and 15th patients (Figure 2A). Step 2 required 63 patients because a grade II complication (total amount of ascites, 15 137 mL during 2 weeks) developed in the 29th patient. This patient was given additional FFP (7440 mL), followed by a predefined dose of 200 mL of albumin. Step 2 therefore required 6 patients with the target value of 2.8 g/dL to pass and was completed in the 63rd patient. Step 3 had a target serum albumin level of 2.6 g/dL and required 34 patients to complete; 3 patients achieved that level. Step 4 was completed after 3 patients reached the target albumin level (2.4 g/dL) and none of the 30 patients had high-grade complications. Step progression was broken at step 5 in the 172nd patient because the serum albumin level on POD2 did not fall to below 2.4 g/dL in 60 consecutive patients (steps 4 and 5 combined).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Albumin levels (A) and corresponding international normalized ratio (INR) (B) in the step progression protocol. The step 1 serum albumin value on postoperative day (POD) 2 was 3.0 g/dL (to convert to grams per liter, multiply by 10), which was decreased by 0.2 g/dL per step thereafter. Step progression was stopped at step 5 because none of the serum albumin levels on POD2 fell below 2.4 g/dL. The median INR on POD2 was 1.15 (range, 0.88-1.46). Similar trends in albumin levels and INR were confirmed.

Overall, only 1 patient (the 29th patient) needed FFP transfusion to treat postoperative intractable ascites. A total of 20 patients (11.6%) received albumin, 25%, solution according to the protocol, and the median serum albumin level rose to 0.2 g/dL (range, 0.1-0.5 g/dL), which corresponded to the value of 1 step. We rechecked serum albumin levels after albumin administration; the level in all but 1 patient rose above the threshold value at each cutoff value. Only the fourth patient did not reach levels above the value in step 1.

We also determined the INR on POD2 (Figure 2B). The median INR was 1.15 (range, 0.88-1.46). The INR was not above 1.50 in any patient. The INR in the patient who needed FFP transfusion because of ascites was 1.14. Similar trends in INR and albumin levels were confirmed.

SURGICAL OUTCOMES

The albumin levels and INR in 172 patients reached nadirs just after the operation and then gradually returned to preoperative levels (Figure 3). The overall incidence of complications according to the Clavien-Dindo classification was 27.9% (48 of 172) (Table 2). There were 47 grade I complications and only 1 grade II complication; no grade III, IV, or V complications occurred during any step. The frequency of complications according to the Clavien-Dindo classification ranged from 23.3% to 33.3%, and there were no significant differences between any step (P = .68). Atelectasis, wound infection, and pleural effusion were frequent complications. There were no significant differences in the types of complications (P = .38). The duration of hospital stay also did not differ significantly between any step (P = .61).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 3. Trends of postoperative serum albumin levels and international normalized ratio (INR) in 172 patients undergoing liver resection. Serum albumin levels and INR tended to recover on postoperative day 2. Data points indicate the median; limit lines, range. To convert albumin to grams per liter, multiply by 10.

Table Graphic Jump LocationTable 2. Postoperative Complications in 172 Patients (2007-2008)
COMPARISON OF 2 PERIODS

Comparing the results between 2 periods, intraoperative blood loss was significantly higher in the previous series (419 vs 536 mL; P = .04) (Table 3). Only 1 of the 172 patients (0.6%) in the present study received additional FFP transfusions (a total of 7440 mL from POD2) because of massive ascites. In our previous series (N = 222), 108 patients (48.6%) received a total of 172 160 mL of FFP. Of the total administered volume of FFP, 45.4% was transfused to 108 patients during or just after the operation, whereas 10.1% was transfused on POD3 or subsequently. The median hospital stay in the present study was significantly shorter than in the previous series (13 vs 16 days; P = .01). The median total surgical costs were also significantly lower in the present study ($17 267 vs $21 061; P = .04), representing an 18% reduction compared with the previous series.

Table Graphic Jump LocationTable 3. Comparison of Outcomes Between 2 Periods

This prospective study showed that the lower safety limit of the serum albumin level allowing FFP transfusion to be avoided was 2.4 g/dL in patients undergoing liver resection. There were neither high-grade complications nor deaths without FFP in eligible patients who had Child-Pugh class A liver function and an intraoperative blood loss of less than 1000 mL. We successfully reduced the transfusion rate from 48.7% in our previous series of patients who met the same eligibility criteria to 0.6% in the present series.

Owing to recent advances in liver operations, most centers now use very limited volumes of FFP transfusion in patients who receive liver resection; however, to our knowledge, no previous study has prospectively determined the cutoff value.3,1214,2629 Patients with no need for perioperative FFP transfusion should be accurately identified and categorized. The objective of FFP transfusion is not only to correct coagulation abnormalities but also to control intractable ascites, which characteristically occurs after liver operations.3,12,29 Makuuchi et al achieved zero operative mortality in more than 1000 liver resections by adhering to a policy of transfusing FFP to maintain total serum protein levels at 6.0 g/dL and serum albumin levels at 3.0 g/dL.3,12 Thus, we used the postoperative serum albumin level as an indicator of the need for FFP transfusion in this step-escalation design. In all patients in the present study, the trend in the INR was similar to that in the albumin level. The INR did not exceed 1.50 in any patient.

In our previous series of 222 patients, 69.2% of FFP was transfused on POD0 and POD1 to compensate for the decrease in the serum albumin level caused by intraoperative blood loss. A similar trend was seen by Martin et al,15 who used a total of 405 U of FFP (median, 4 U [range, 1-23]) in 260 patients on the basis of the prothrombin values. In their study, 77% of the patients received transfusions within POD2. However, our results suggest that early postoperative use of FFP can be avoided in patients who meet the eligibility criteria that we used. In the present study, patients received albumin, 25%, solution according to the step-progression protocol; all of these patients had serum albumin values higher than 2.4 g/dL. Our results indicate that such patients do not require albumin transfusions.

In clinical oncology, the concept underlying the step-escalation design is to attain the maximum tolerated dosage without reaching dose-limiting toxic effects in the minimum number of patients.21 The 3 + 3 cohort design contributes to reducing the number of participants treated at biologically inactive doses and decreases the number of patients per step. To our knowledge, this approach has not been used previously to establish criteria for transfusion in operations. Oncologic trials classify toxic effects according to the 0 to 5 grading scales of the National Cancer Institute's Common Toxicity Criteria (http://ctep.cancer.gov/). We used the Clavien-Dindo classification to define a complication grade–based stopping rule.23 This modification and criteria for patient enrollment resulted in zero operative mortality and low morbidity rates: only 1 patient developed grade II complications in this study. This step-progression protocol can minimize safety-related risks, and we believe that our prospective approach was more appropriate than retrospective studies and allowed the development of optimal FFP transfusion criteria with minimal clinical risk.

One limitation of the present study is that the protocol could not include all patients who underwent liver resection. Further investigations are needed in patients with greater amounts of blood loss or more severe liver dysfunction. We speculated that blood loss of less than 1500 mL is practical and showed that FFP transfusion was not necessary in patients with this volume of blood loss when our approach was used. It might not be possible to include patients with Child-Pugh class B liver function because it would be difficult to ensure the safety of all participants in the present phase 1 manner. To obtain more robust evidence, we are planning a randomized study to confirm that an albumin level of 2.4 g/dL is a reliable value that will help to avoid unnecessary FFP use after liver resection.30

This prospective study clearly showed that the prophylactic correction of laboratory data abnormalities did not influence patient outcomes after general liver operations. The use of our step-progression design successfully reduced the proportion of patients who received transfusions after liver resection from 48.6% to 0.6% and remarkably decreased total medical costs by $3794 per patient without increasing complications. Our results are expected to provide the basis for developing optimal criteria for the use of FFP transfusion and to contribute to avoiding the unnecessary use of FFP in liver resection.

Correspondence: Tadatoshi Takayama, MD, Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Oyaguchikami-machi, Itabashi-ku, Tokyo 173-8610, Japan (takayama.tadatoshi@nihon-u.ac.jp).

Accepted for Publication: May 19, 2011.

Author Contributions:Study concept and design: Yamazaki, Takayama, and Fujii. Acquisition of data: Yamazaki, Kimura, Moriguchi, Higaki, and Nakayama. Analysis and interpretation of data: Yamazaki. Drafting of the manuscript: Yamazaki, Takayama, Fujii, and Makuuchi. Critical revision of the manuscript for important intellectual content: Takayama, Kimura, Moriguchi, Higaki, Nakayama, Fujii, and Makuuchi. Statistical analysis: Yamazaki and Takayama. Obtained funding: Takayama. Study supervision: Takayama, Fujii, and Makuuchi.

Financial Disclosure: None reported.

Funding/Support: This work was supported by the 106th Annual Congress of Japan Surgical Society Memorial Surgical Research Fund and the 2011 Research Grant of the Toki Fund, Nihon University School of Medicine.

Grazi GL, Ercolani G, Pierangeli F,  et al.  Improved results of liver resection for hepatocellular carcinoma on cirrhosis give the procedure added value.  Ann Surg. 2001;234(1):71-78
PubMed   |  Link to Article
Jarnagin WR, Gonen M, Fong Y,  et al.  Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade.  Ann Surg. 2002;236(4):397-407
PubMed   |  Link to Article
Imamura H, Seyama Y, Kokudo N,  et al.  One thousand fifty-six hepatectomies without mortality in 8 years.  Arch Surg. 2003;138(11):1198-1206
PubMed   |  Link to Article
Poon RT, Fan ST, Lo CM,  et al.  Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database.  Ann Surg. 2004;240(4):698-710
PubMed
Pessaux P, Regimbeau JM, Dondéro F, Plasse M, Mantz J, Belghiti J. Randomized clinical trial evaluating the need for routine nasogastric decompression after elective hepatic resection.  Br J Surg. 2007;94(3):297-303
PubMed   |  Link to Article
Mullen JT, Ribero D, Reddy SK,  et al.  Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatectomy.  J Am Coll Surg. 2007;204(5):854-864
PubMed   |  Link to Article
Sima CS, Jarnagin WR, Fong Y,  et al.  Predicting the risk of perioperative transfusion for patients undergoing elective hepatectomy.  Ann Surg. 2009;250(6):914-921
PubMed   |  Link to Article
 Transfusion alert: use of autologous blood: National Heart, Lung, and Blood Institute Expert Panel on the use of autologous blood.  Transfusion. 1995;35(8):703-711
PubMed   |  Link to Article
Hashimoto T, Kokudo N, Orii R,  et al.  Intraoperative blood salvage during liver resection: a randomized controlled trial.  Ann Surg. 2007;245(5):686-691
PubMed   |  Link to Article
Jarnagin WR, Gonen M, Maithel SK,  et al.  A prospective randomized trial of acute normovolemic hemodilution compared to standard intraoperative management in patients undergoing major hepatic resection.  Ann Surg. 2008;248(3):360-369
PubMed
Hasegawa K, Takayama T, Orii R,  et al.  Effect of hypoventilation on bleeding during hepatic resection: a randomized controlled trial.  Arch Surg. 2002;137(3):311-315
PubMed   |  Link to Article
Ishizawa T, Hasegawa K, Kokudo N,  et al.  Risk factors and management of ascites after liver resection to treat hepatocellular carcinoma.  Arch Surg. 2009;144(1):46-51
PubMed   |  Link to Article
Stanworth SJ, Brunskill SJ, Hyde CJ, McClelland DB, Murphy MF. Is fresh frozen plasma clinically effective? a systematic review of randomized controlled trials.  Br J Haematol. 2004;126(1):139-152
PubMed   |  Link to Article
Segal JB, Dzik WH.Transfusion Medicine/Hemostasis Clinical Trials Network.  Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review.  Transfusion. 2005;45(9):1413-1425
PubMed   |  Link to Article
Martin RC II, Jarnagin WR, Fong Y, Biernacki P, Blumgart LH, DeMatteo RP. The use of fresh frozen plasma after major hepatic resection for colorectal metastasis: is there a standard for transfusion?  J Am Coll Surg. 2003;196(3):402-409
PubMed   |  Link to Article
 Practice parameter for the use of fresh-frozen plasma, cryoprecipitate, and platelets: Fresh-frozen Plasma, Cryoprecipitate, and Platelets Administration Guidelines Development Task Force of the College of American Pathologists.  JAMA. 1994;271(10):777-781
PubMed   |  Link to Article
 Practice guidelines for blood component therapy: a report by the American Society of Anesthesiologists Task Force on Blood Component Therapy.  Anesthesiology. 1996;84(3):732-747
PubMed   |  Link to Article
Japanese Ministry of Health and Welfare.  Guideline for usage of blood products, revised version [in Japanese]. 2005. http://www.mhlw.go.jp/new-info/kobetu/iyaku/kenketsugo/5tekisei3a.html. Accessed October 10, 2009
Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study.  Arch Surg. 1999;134(1):36-42
PubMed   |  Link to Article
Virani S, Michaelson JS, Hutter MM,  et al.  Morbidity and mortality after liver resection: results of the patient safety in surgery study.  J Am Coll Surg. 2007;204(6):1284-1292
PubMed   |  Link to Article
Ivy SP, Siu LL, Garrett-Mayer E, Rubinstein L. Approaches to phase 1 clinical trial design focused on safety, efficiency, and selected patient populations: a report from the Clinical Trial Design Task Force of the National Cancer Institute Investigational Drug Steering Committee.  Clin Cancer Res. 2010;16(6):1726-1736
PubMed   |  Link to Article
Kimura Y, Takayama T, Inoue K,  et al.  Criteria for transfusion of fresh frozen plasma after hepatectomy for hepatocellular carcinoma.  Nihon Univ J Med. 2006;48(3):71-78
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.  Ann Surg. 2004;240(2):205-213
PubMed   |  Link to Article
Makuuchi M, Kosuge T, Takayama T,  et al.  Surgery for small liver cancers.  Semin Surg Oncol. 1993;9(4):298-304
PubMed   |  Link to Article
Takayama T, Makuuchi M, Kubota K,  et al.  Randomized comparison of ultrasonic vs clamp transection of the liver.  Arch Surg. 2001;136(8):922-928
PubMed   |  Link to Article
Youssef WI, Salazar F, Dasarathy S, Beddow T, Mullen KD. Role of fresh frozen plasma infusion in correction of coagulopathy of chronic liver disease: a dual phase study.  Am J Gastroenterol. 2003;98(6):1391-1394
PubMed   |  Link to Article
Abdel-Wahab OI, Healy B, Dzik WH. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities.  Transfusion. 2006;46(8):1279-1285
PubMed   |  Link to Article
Pruvot FR, Roumilhac D, Jude B, Declerck N. Fresh frozen plasma use in liver resection.  J Am Coll Surg. 2003;197(4):698-701
PubMed   |  Link to Article
Kaibori M, Saito T, Matsui K, Yamaoka M, Kamiyama Y. Impact of fresh frozen plasma on hepatectomy for hepatocellular carcinoma.  Anticancer Res. 2008;28(3B):1749-1755
PubMed
The Standards of Reporting Trials Group.  A proposal for structured reporting of randomized controlled trials.  JAMA. 1994;272(24):1926-1931
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Step progression profile. To convert albumin to grams per liter, multiply by 10.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Albumin levels (A) and corresponding international normalized ratio (INR) (B) in the step progression protocol. The step 1 serum albumin value on postoperative day (POD) 2 was 3.0 g/dL (to convert to grams per liter, multiply by 10), which was decreased by 0.2 g/dL per step thereafter. Step progression was stopped at step 5 because none of the serum albumin levels on POD2 fell below 2.4 g/dL. The median INR on POD2 was 1.15 (range, 0.88-1.46). Similar trends in albumin levels and INR were confirmed.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 3. Trends of postoperative serum albumin levels and international normalized ratio (INR) in 172 patients undergoing liver resection. Serum albumin levels and INR tended to recover on postoperative day 2. Data points indicate the median; limit lines, range. To convert albumin to grams per liter, multiply by 10.

Tables

Table Graphic Jump LocationTable 1. Analysis of Postoperative Complications in 222 Patients (2002-2006)a
Table Graphic Jump LocationTable 2. Postoperative Complications in 172 Patients (2007-2008)
Table Graphic Jump LocationTable 3. Comparison of Outcomes Between 2 Periods

References

Grazi GL, Ercolani G, Pierangeli F,  et al.  Improved results of liver resection for hepatocellular carcinoma on cirrhosis give the procedure added value.  Ann Surg. 2001;234(1):71-78
PubMed   |  Link to Article
Jarnagin WR, Gonen M, Fong Y,  et al.  Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade.  Ann Surg. 2002;236(4):397-407
PubMed   |  Link to Article
Imamura H, Seyama Y, Kokudo N,  et al.  One thousand fifty-six hepatectomies without mortality in 8 years.  Arch Surg. 2003;138(11):1198-1206
PubMed   |  Link to Article
Poon RT, Fan ST, Lo CM,  et al.  Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database.  Ann Surg. 2004;240(4):698-710
PubMed
Pessaux P, Regimbeau JM, Dondéro F, Plasse M, Mantz J, Belghiti J. Randomized clinical trial evaluating the need for routine nasogastric decompression after elective hepatic resection.  Br J Surg. 2007;94(3):297-303
PubMed   |  Link to Article
Mullen JT, Ribero D, Reddy SK,  et al.  Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatectomy.  J Am Coll Surg. 2007;204(5):854-864
PubMed   |  Link to Article
Sima CS, Jarnagin WR, Fong Y,  et al.  Predicting the risk of perioperative transfusion for patients undergoing elective hepatectomy.  Ann Surg. 2009;250(6):914-921
PubMed   |  Link to Article
 Transfusion alert: use of autologous blood: National Heart, Lung, and Blood Institute Expert Panel on the use of autologous blood.  Transfusion. 1995;35(8):703-711
PubMed   |  Link to Article
Hashimoto T, Kokudo N, Orii R,  et al.  Intraoperative blood salvage during liver resection: a randomized controlled trial.  Ann Surg. 2007;245(5):686-691
PubMed   |  Link to Article
Jarnagin WR, Gonen M, Maithel SK,  et al.  A prospective randomized trial of acute normovolemic hemodilution compared to standard intraoperative management in patients undergoing major hepatic resection.  Ann Surg. 2008;248(3):360-369
PubMed
Hasegawa K, Takayama T, Orii R,  et al.  Effect of hypoventilation on bleeding during hepatic resection: a randomized controlled trial.  Arch Surg. 2002;137(3):311-315
PubMed   |  Link to Article
Ishizawa T, Hasegawa K, Kokudo N,  et al.  Risk factors and management of ascites after liver resection to treat hepatocellular carcinoma.  Arch Surg. 2009;144(1):46-51
PubMed   |  Link to Article
Stanworth SJ, Brunskill SJ, Hyde CJ, McClelland DB, Murphy MF. Is fresh frozen plasma clinically effective? a systematic review of randomized controlled trials.  Br J Haematol. 2004;126(1):139-152
PubMed   |  Link to Article
Segal JB, Dzik WH.Transfusion Medicine/Hemostasis Clinical Trials Network.  Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review.  Transfusion. 2005;45(9):1413-1425
PubMed   |  Link to Article
Martin RC II, Jarnagin WR, Fong Y, Biernacki P, Blumgart LH, DeMatteo RP. The use of fresh frozen plasma after major hepatic resection for colorectal metastasis: is there a standard for transfusion?  J Am Coll Surg. 2003;196(3):402-409
PubMed   |  Link to Article
 Practice parameter for the use of fresh-frozen plasma, cryoprecipitate, and platelets: Fresh-frozen Plasma, Cryoprecipitate, and Platelets Administration Guidelines Development Task Force of the College of American Pathologists.  JAMA. 1994;271(10):777-781
PubMed   |  Link to Article
 Practice guidelines for blood component therapy: a report by the American Society of Anesthesiologists Task Force on Blood Component Therapy.  Anesthesiology. 1996;84(3):732-747
PubMed   |  Link to Article
Japanese Ministry of Health and Welfare.  Guideline for usage of blood products, revised version [in Japanese]. 2005. http://www.mhlw.go.jp/new-info/kobetu/iyaku/kenketsugo/5tekisei3a.html. Accessed October 10, 2009
Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study.  Arch Surg. 1999;134(1):36-42
PubMed   |  Link to Article
Virani S, Michaelson JS, Hutter MM,  et al.  Morbidity and mortality after liver resection: results of the patient safety in surgery study.  J Am Coll Surg. 2007;204(6):1284-1292
PubMed   |  Link to Article
Ivy SP, Siu LL, Garrett-Mayer E, Rubinstein L. Approaches to phase 1 clinical trial design focused on safety, efficiency, and selected patient populations: a report from the Clinical Trial Design Task Force of the National Cancer Institute Investigational Drug Steering Committee.  Clin Cancer Res. 2010;16(6):1726-1736
PubMed   |  Link to Article
Kimura Y, Takayama T, Inoue K,  et al.  Criteria for transfusion of fresh frozen plasma after hepatectomy for hepatocellular carcinoma.  Nihon Univ J Med. 2006;48(3):71-78
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.  Ann Surg. 2004;240(2):205-213
PubMed   |  Link to Article
Makuuchi M, Kosuge T, Takayama T,  et al.  Surgery for small liver cancers.  Semin Surg Oncol. 1993;9(4):298-304
PubMed   |  Link to Article
Takayama T, Makuuchi M, Kubota K,  et al.  Randomized comparison of ultrasonic vs clamp transection of the liver.  Arch Surg. 2001;136(8):922-928
PubMed   |  Link to Article
Youssef WI, Salazar F, Dasarathy S, Beddow T, Mullen KD. Role of fresh frozen plasma infusion in correction of coagulopathy of chronic liver disease: a dual phase study.  Am J Gastroenterol. 2003;98(6):1391-1394
PubMed   |  Link to Article
Abdel-Wahab OI, Healy B, Dzik WH. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities.  Transfusion. 2006;46(8):1279-1285
PubMed   |  Link to Article
Pruvot FR, Roumilhac D, Jude B, Declerck N. Fresh frozen plasma use in liver resection.  J Am Coll Surg. 2003;197(4):698-701
PubMed   |  Link to Article
Kaibori M, Saito T, Matsui K, Yamaoka M, Kamiyama Y. Impact of fresh frozen plasma on hepatectomy for hepatocellular carcinoma.  Anticancer Res. 2008;28(3B):1749-1755
PubMed
The Standards of Reporting Trials Group.  A proposal for structured reporting of randomized controlled trials.  JAMA. 1994;272(24):1926-1931
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

1,856 Views
9 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
Jobs